Geriatric nursing: A growing field

For too long, the stigma of LTC facilities has negatively impacted the delivery of healthcare for the nation’s elderly population. Stigmas that have been associated to LTC nurses and students include impressions that nursing home nurses do not have the same skills as hospital nurses; the nurse/patient ratios are too high in long-term care—inadequate certified nurse aide staffing, most graduate nurses want to work in specialty areas—caring for the elderly is a less attractive option; nursing homes are places where nurses work until they can get hired at a hospital; and other practitioners often look down on LTC nurses.

In a recent literature review, Koh2 concluded that negative student clinical experiences in long-term care may be related to students’ perceptions of caring for the elderly and a lack of pre-placement orientation to the practice environment. Conversely, “student exposure to experienced nurse faculty, or 'link lecturers,' which provided both didactic information and supervision in their own practice settings, was viewed by students as positive and inspirational.”3 The information from this study can be used as a framework to empower nurse educators in developing curricula that incorporate strategies for teaching for a sense of salience and situated use of knowledge.4 Preparing students in advance of their clinical placement with geriatrics experts can optimize the learning experience and reduce the stigmas that have impacted long-term care.

Today, empowered by the work of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine,1 nurses are realizing their role in this vision. As stated in the report, “the nursing profession has the potential capacity to implement wide-reaching changes in the health care system … by virtue of their regular, close proximity to patients and their scientific understanding of care processes across the continuum of care, nurses have a considerable opportunity to act as full partners with other health professionals and lead in the improvement and redesign of the health care system and its practice environment.”           


Geriatric nursing is a person-centered practice and requires the best of nursing. Raterink identified facilitators and barriers to critical-thinking skills for LTC nurses.5 Issues identified include teamwork, staff support, staffing patterns that allowed for consistency in care and team effort, administrative engagement—lack of communication and appreciation for hard work by the management staff, frustration with high volume of paperwork, poor physical state of the work environment and lack of adequate vacation and sick benefits.5 Study participants saw the level of complexity and acuity LTC patients as an opportunity to improve/maintain their clinical and critical-thinking skills. These findings suggest that the organizational structure and culture play a significant role in supporting these skills in LTC nursing staff.

Understanding barriers to effective communication is an essential aspect of safe patient care. In a recent study,6 telephone communication was identified as occurring more often in long-term care than in any other clinical setting. For this reason, it is important to understand nurses’ perceptions of nurse–physician telephone communication that compromise care delivery and to identify strategies for improvement. Barriers include: lack of physician openness to communication, logistic challenges, a lack of professionalism and language barriers.

Physicians in the study reported that nurses needed to be brief and prepared with relevant clinical information when communicating with them. As identified by the researchers, a combination of nurse and physician behaviors contributes to ineffective communication. “Interventions to improve the effectiveness of communication in the LTC setting must target both nurses and physicians to create a culture that facilitates effective communication with improved patient safety and healthcare quality as the ultimate goal.”6


Across the nation, nursing homes are embracing the philosophy and value of culture change. Nurses thrive in this environment that provides hope and empowerment of the elders and staff. To transform the institutional model, new approaches to care delivery focus on person-directed model, which helps to alleviate the fear of individuals needing institutional care and contributes to the overall job satisfaction of nurses.7

The John A. Hartford Foundation's Centers of Geriatric Nursing Excellence National Nursing Home Collaborative creates opportunities for geriatric nurses to change the structures and processes of elder care in LTC facilities. When nurses engage in creating, implementing and sustaining a professional practice model, they gain a renewed appreciation for nurses.8

The Everyday Excellence Framework for Professional Nursing Practice in Long Term Care is based upon eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence.8

One such organization, LeadingAge Texas, is committed to all eight principles and committed to developing enhancement programs tailored to meet the learning needs of nursing personnel, including CNAs. A designated Nurse Leader provides development for the 250 organizations in this association. A Nurse Peer Group provides development of the eight Advancing Excellence principles.


Research has shown that nurses empowered through education experience increased job satisfaction and stay longer. LTC nurses must be equipped with information relevant to aging in order to deal with the many challenges faced on a continual basis. In a publication by McConnell, Lekan, and Corazzini,9 the authors conclude that LTC nursing increasingly includes caring for greater complexities of residents. The argument is that increased acuity requires that nursing staff receive adequate training to provide care that meets each resident’s individual needs. While job skills may be learned over time, frequently new LTC nurse graduates are not equipped to critically think when presented with complex problems. Such issues can create concerns and increase the liability for the new graduate and employer. 

One way this knowledge gap is being filled is through LeadingAge Texas-Educational Institute on Aging (EIA) in Austin. Educational opportunities are offered to nurses, with an emphasis on creativity and flexibility that does not follow traditional methods of classroom training. Examples include distance learning alternatives that are technology driven-web based, teleconference, and online formats. While in the past distance learning was not a primary education source, it is becoming the norm. Such opportunities must be offered that break away from strictly traditional methods of education delivery. 

Furthermore, creative solutions through technology broaden the range of marketing opportunities to meet the educational needs of rural and underserved populations of LTC nursing staff. Distance learning education offers a budget-conscious alternative that saves money and supports an already burdened bottom line. It offers education to nurses who might not otherwise attend a conference or workshop away from the workplace. 

Breaking traditional boundaries has the potential to change the future of education for nurses and others in the LTC profession. Education strengthens nursing practice, provides a foundation for quality services in long-term care, and must be viewed by all stakeholders as a component that is more than just meeting regulatory requirements. 

Furthermore, LeadingAge Texas taps into the political side of nursing through an annual “Day at the Capitol” event where nurses attend an all-day session at the state capitol in Austin. This event provides nurses with an opportunity to meet political leaders and share successes and concerns of the LTC industry from a nurse’s point of view. A similar event is currently in development where LeadingAge Texas has partnered with Texas Tech University Health Sciences Center to offer master’s and doctoral students an opportunity to visit the Austin headquarters and learn the process of advocacy and the behind-the-scenes political workings.

In a field where care is so dependent on reimbursement and regulatory issues, participation in the policy and regulatory arenas is vitally important. These are examples of the ongoing efforts to attract nurses into the ever-changing field of aging services.

Pearl Merritt, EdD, MSN, MS, RN, isRegional Dean at Texas Tech University Health Sciences Center. LaNeigh Harkness, MSN, RN, is Assistant Professor at Texas Tech University Health Sciences Center, Anita Thigpen Perry School of Nursing. Vickie Ragsdale, PhD, RN, is an LTC consultant and Project Director for the Sears Methodist Retirement System and serves on the Texas Center for Workforce Studies. For more information, email Ms. Merritt at


  1. Institute of Medicine. The future of Nursing: Leading change, advancing health. Washington, DC: National Academies Press, 2011.
  2. Koh LC. Student attitudes and educational support in caring for older people: A review of literature. Nurse Education in Practice 2012;1:16-20.
  3. Scudder L. Nursing care for the aged: Can students handle it?, 2012. Available
  4. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A call for radical transformation. Stanford, CA: Jossey-Bass, 2010.
  5. Raterink G. A descriptive inquiry of the definitions of critical thinking and enhancers and barriers reported by nurses working in Long-term care facilities. Journal of Continuing Education in Nursing 2008;9:407-12.
  6. Tjia,J., Mazor, K. M., Field, T., Meterko, V., Spenard, A., and Gurwitz, J. H. (2009). Nurse-Physician communication in the Long-term care setting: Perceived barriers and impact on patient safety. Journal of Patient Safety. 5: 145-152.
  7. Pioneer Network. Who we are: Our values and Principles. Available at: Principles.php.
  8. Lyons S, Specht J, Karlman S, Maas M. Everyday excellence: A framework for professional nursing practice in long term care. Gerontological Nursing2008;3:217-28.
  9. McConnell ES, Lekan D, Corazzini KN. Assuring the adequacy of staffing of long-term care, strengthening the caregiving workforce, and making long-term care a career destination of choice: From mission impossible to mission critical?North Carolina Medical Journal2010;2:153-7.

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