Geriatric Nursing: The Challenges in the Middle East

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Abdulrazak Abyad Correspondence: A. Abyad, MD, MPH, MBA, AGSF , AFCHSE CEO, Abyad Medical Center, Lebanon. Chairman, Middle-East Academy for Medicine of President, Middle East Association on Age & Alzheimer's Coordinator, Middle-East Primary Care Research Coordinator, Middle-East Network on Aging Email: aabyad@cyberia.net.lb

Abstract As this century progresses nurses in the Middle-East will be increasingly concerned with the aging population. Older Arabs utilize extensively more healthcare services than more youthful Arabs and their needs are often multifaceted. The health care system frequently fails to provide high-quality services in the best way to address their issues. In reality, the instruction and preparing of the whole human services workforce regarding the scope of necessities of older adults remains woefully deficient. Enrollment and maintenance of all types of health care workers is an important problem, particularly in long-term care settings. Unless move is made promptly, the health care workforce will not have the limit (in both size and capacity) to address the issues of more older patients later on. Key words: Nursing, Geriatrics, Middle East

Background
The aging of the baby boom population, joined with an increase in life expectancy and a diminishing in the relative number of more youthful persons, will create a setting where older adults make up a much larger percentage of the Regional population than has ever before been the case. While this population surge has been anticipated for quite a long time, little has been done to set up the health care workforce for its coming. A significant change in the delivery of health and social care for older people, will be portrayed by shorter, more medically intense spells in hospitals, extension of care in the community, and a huge increment in homes care. The present strategy drive is the advancement of autonomy inside community care structure through an accentuation on rehabilitation and re-enablement.

Amidst this rapid progress is the defenseless older person whose mind boggling requirements are met by a range of providers. The more defenseless a man is, the more power dwells with the different providers; the individual turns into a detached beneficiary of services instead of a dynamic member in choices about care.

A double need has emerged: to enhance the mentalities and information base of those providing care; and to enhance the older individual's pathway and experience as they move through an extensive variety of continually evolving provisions. Older individuals are the significant clients of health and social care. Various elements have changed the pattern of this utilization in late decades. More noteworthy access to more powerful medicinal medications, enhanced lodging conditions, more far reaching social consideration provision and closure of the customary long term care hospitals have all had influence in this change. For some more older individuals, and especially the most frail, the pattern of need is of some level of continuing care, interspersed with acute episodes that require quick access to medical treatment, nursing and therapy.

As hospital stay was shortened, this coupled with the lack of rehabilitation facilities led to the development of the home care sector. A number of reports (1) and national audits (2-4) in the late 1990s showed that the lack of rehabilitation facilities were insufficient, in addition to fragmentation of care was leading to systematic inefficiency. There is a need to coordinate elderly services in a comprehensive intelligible manner, under the general vital heading of advancing autonomy and independence. The rising acute hospital admission rate was mostly identified with inappropriate admissions and somewhat to admissions related to previously incomplete rehabilitation, and therefore conceivably preventable (5).

Model for Training of Nursing in the Aging Field
Therefore there is great need to develop and train nurses in the field of ageing. There is a need to develop and encourage the specialty of geriatric nursing. Professional nurses represent the main sector of the health care workforce accountable for patient care in most health care settings. In the USA the professional nurse workforce comprises registered nurses (RNs) and advanced practice registered nurses (APRNs), who are RNs who followed master's degree programs. With limited exemptions, all professional nurses are part of the care of older adults. Notwithstanding immediate consideration, professional nurses oversee licensed practical nurses (LPNs) and certified nurse aides (CNAs). In the United Kingdom they come with the model of Older People's Specialist Nurse (OPSN). This is considered in the UK as an important part of the strategy to improve care of older people, in hospitals, in the community, in care homes and across the service interfaces.

The essential role of OPSN is that of a specialist clinical expert working with older individuals and their families. The role incorporates clinical examination, interview, educating and administration (6-8). To be formally perceived as an expert professional, attendants are relied upon to have embraced a program of training to a standard set by the UKCC of in any event first degree level and exhibit accomplishment in the territories of clinical practice, administration, practice development and care and program administration.

Suitable training for the OPSN necessitates:
• Sufficient and sound clinical experience working with older people;
• Post-registration development in the distinctive and 'exceptional' aspects of older people's health and social circumstances and necessities;
• Post-registration advancement in comprehension the particular issues of later life e.g. the social gerontological literature, the scope of living circumstances and individual and interpersonal organizations; and
• Attributes and skills which empower the nurse to react expertly to the needs of elderly individuals.

It is foreseen that, as an after effect of studying for this degree, the OPSN will have the capacity to give, advance and create talented comprehensive consideration to older people in a variety of situations. The NSF has proposed service models with standards for falls, stroke, and Intermediate care. Now and again care pathways will encourage their usage. The scope of aptitudes required by the workforce to convey this way to care does not exist in a specific profession or part of the service. Those customarily found in hospital based departments (i.e. specialist departments ) will progressively be required in the community. Working in an interdisciplinary manner presents difficulties to all.

A key service development central both to the NHS Plan and the NSF is the single process of assessment, took place in 2002 for vulnerable older adults. The extent of this generic assessment procedure was depicted in the NSF. It is imagined that nurses medical, social laborers, and advisors will be prepared to play out these assessments, which may then connect into fundamental service provision or to further expert evaluations and specialists services. For the client, the single evaluation procedure can be seen as a key part of entire frameworks working. At present the workforce is deficient, most likely in number and surely in abilities, to convey this goal. The OPSN could be a key asset to give leadership for nursing and add to cross limit working.

The OPSN functioning as a component of an expert group with geriatricians, therapists, social specialists and others over all settings, would share a dream and responsibility for the thorough conveyance of services as well as developing good practice in nursing older people.
Specialist nurses can work in a variety of settings and across boundaries. They can work with nursing home staff, acute care, hospital, home care, hospital or primary care. Each OPSN would work with a specific community of older people i.e. they will know the ageing population in their locality. Their role will develop with the requirements and circumstances of every area or territory and certain territories and obligations are liable to shift from post to post and inside the same post after some time, keeping in mind the end goal to mirror the changing needs of older people in each locality.

Registered Nurses
Likewise with different professions, nurses by and large get practically no preparation in the rules that underlie geriatric nursing in their fundamental nursing instruction. In the States 31 percent of new RNs got baccalaureate degrees, yet only third of the baccalaureate programs required a course centered around geriatrics. All baccalaureate programs incorporate some geriatric materials, yet the degree of this content is obscure (9). While 42 percent of RNs get their underlying instruction through associate degree nursing programs (10), the level of reconciliation of geriatrics into these programs is additionally obscure. Given the lack of geriatric content in training programs, it is suitable to accept that most practicing RNs have minimal formal readiness in geriatrics.

There exist various endeavors aimed at guaranteeing nursing competency in geriatric care. In 2000, for instance, the American Association of Colleges of Nursing (AACN) created rules for geriatric competencies in baccalaureate programs. The National Council of State Boards of Nursing (NCSBN) mapped those rules against the National Council Licensure Examination (NCLEX), which is required for licensure of all attendants, to guarantee sufficient testing on geriatric issues (11). Still, all the more should be done to break down the profundity of this content (12). In the Region there is a need for both different public and private efforts intended at expanding the geriatric content of nursing programs and creating geriatric nursing leaders. Grants should be made available to nursing schools to build the incorporation of geriatrics into their core curricula.

Advanced Practice Registered Nurses
In the States a RN may turn into an APRN by getting a graduate degree and may get to be certified either through a national certifying examination or through state accreditation mechanisms. An APRN capacities as an autonomous health care provider, tending to the full scope of a patient's wellbeing issues and needs inside an area of specialization. There are various diverse sorts of APRNs, including: nurse practitioners (NPs), who provide primary care; clinical nurse specialists, who classically specialize in a medical or surgical specialty; certified nurse anesthetists; and certified nurse mid- wives. The pipeline for creating APRNs with a specialization in geriatrics is deficient. Likewise with different sorts of nurses, the John A. Hartford Foundation has been a key supporter in the improvement of the geriatric APRN workforce. Specifically, the Building Academic Geriatric Nursing Capacity Scholars and Fellows Awards Program targets doctoral and post-doctoral nurses, and APRNs who need to divert their professions toward geriatrics (13).

NPs represent an especially imperative part of the workforce tending for older adults as a result of their capacity to give essential care, and in addition watch over patients preceding, amid, and after an acute hospitalization furthermore to provide care to occupants in institutional long term care settings. NPs treat a lopsided number of more older adults-23 percent of office visits and 47 percent of hospital outpatient visits with NPs are made by individuals 65 and more (14). Besides, NPs watch over a higher extent of elderly poor adults than do doctors or doctor collaborators (15). At last, NPs have been appeared to give top notch high quality care and be cost-effective (16-18).

While APRNs watch over extensive numbers of older adults in ambulatory care, hospitals, and institutional long-term care settings, APRN education programs are deficient in specific geriatric requirements. The AACN issues a set of competencies called Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care (19,20), however it doesn't require that these abilities be consolidated into educational programs. Some of these skills include:

• Ability to differentiate between sickness and normal aging;
• Assessment of geriatric disorders;
• Documentation of changes in mental status;
• Education of patients and their families about prevention, and end-of-life consideration;
• Assessment of social and other worldly concerns; and
• Collaboration with other health care professionals.

Licensed Practical Nurses
In a number of countries in the Region there is a different route toward practicing nursing including various terminology for practical nurses. These usually follow technical vocational programs leading to various degrees. These programs vary from one to three years. In Lebanon they go from BT to TS to LT. LPNs have a more limited scope of practice than RNs, but this scope can vary widely among countries, especially in light of the nursing shortage.

In the States 26 percent of all LPNs working in nursing homes; LPNs are particularly vital to the care of older adults in long term care settings (21). LPNs regularly give more hours of care per nursing home occupant every day than do RNs (22). LPNs get around 1 year of preparing through specialized or professional schools or through junior or community colleges. With experience and preparation, LPNs may direct nurse aides.

Regional Situation
In the area there is a present and approaching nursing deficiency that has gotten much consideration. Gerontology training in nursing programs was noted in ten Arab countries (Bahrain, Jordan, Lebanon, Tunisia Libya, Morocco, Oman, Palestine, Qatar and Syrian Arab Republic). Also, men remain under-represented in the nursing calling and should be considered for enrollment endeavors to alleviate workforce deficiencies.

The keys to enable the nursing profession to effectively cope with the challenge of caring for the elderly lie in specialized training that equips nurses with the knowledge needed. The concept of nurse practitioner is not acceptable in the area, although nurse practitioners are increasingly popular in the USA. There is a need to incorporate gerontological nursing preparation into basic nursing education (23). The teaching of a Nursing Home Program is of vital importance. It will help nursing homes gain access to the research and educational resources of universities with student access to actual clinical nursing situations in real life. An attempt to create a close relationship between facilities and private institutes providing health care services to the elderly and institutions responsible for education and research should be made.

Recommendations
There is a need to encourage nurse competence in aging through initiatives in the Region. In doing so the quality of health care of the elderly will improve. These initiatives may include :

• Enhancing Geriatric Activities of National Specialty Nursing Associations
• Promoting the creation of Gerontological Nursing Certification to encourage specialty nurses to obtain dual certification and validate their geriatric competence along with their specialty expertise.
• Providing a Web-based Comprehensive Geriatric Nursing Resource Center
• Encourage regional collaboration in the area

Conclusion
Nursing must focus upon the entire spectrum of health and develop interventions geared, not only toward the individual patient, but also toward the family and community. It is a prime responsibility of nursing to encourage elderly people to optimize their physical, social, and psychological function during changes in their state of health.

References
1. Community Health Care for Elderly People. The Clinical Standards Advisory Group,1998.

2. Lying in Wait. The Use of Medical Beds in Acute Hospitals. Audit Commission. HMSO, 1992.

3. The Coming of Age: Improving Care Services for Older People. Audit Commission, 1997.

4. The Way to Go Home, Rehabilitation and Remedial
services for Older People. Audit Commission, 2000. Website: www.audit-commission.gov.uk.

5. United They Stand. Coordinating Care for Elderly Patients with Hip Fractures. Audit Commission. HMSO, 1995.

6. The Health and Care of Older People in Care Homes. A Comprehensive, Interdisciplinary Approach. Report of a joint working party, Royal College of Physicians (RCP), Royal College of Nursing and British Geriatrics Society. RCP, London, 2000.

7. Future Directions for Gerontology: a Nursing Perspective. Ford P, McCormack B. Nurse Education Today 2000;20: 389-94.

8. The Key Attributes of a Gerontological Nurse Specialist. Ford P, McCormack B. Elderly Care 1999; 1 : 4-26. 15 Exploring New Roles in Practice. Read S et al. Sheffield, SCHARR, 1999.

9. Berman A., M. Mezey, M. Kobayashi, T. Fulmer, J. Stanley, D. Thornlow, and P. Rosenfeld. 2005. Gerontological nursing content in baccalaureate nursing programs: Comparison of findings from 1997 and 2003. Journal of Professional Nursing 21(5):268-275

10. HRSA. 2006b. The registered nurse population: Findings from the March 2004 National Sample Survey of Registered Nurses. Washington, DC: HRSA.

11. Wendt A. 2003. Mapping geriatric nursing competencies to the 2001 NCLEX-RN test plan. Nursing Outlook 51(4):152-157.

12. Bednash G., C. Fagin, and M. Mezey. 2003. Geriatric content in nursing programs: A wake- up call. Nursing Outlook 51(4):149-150.

13. Fagin, C. M., P. D. Franklin, D. I. Regenstreif, and G. J. Huba. 2006. Overview of the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Initiative. Nursing Outlook 54(4):173-182.

14. Center for Health Workforce Studies. 2005. The impact of the aging population on the health workforce in the United States. Rensselaer, NY: School of Public Health, University at Albany.

15. Cipher, D. J., R. S. Hooker, and E. Sekscenski. 2006. Are older patients satisfied with physician assistants and nurse practitioners? Journal of the American Academy of Physician Assistants 19(1):36, 39-40, 42-44.

16. Hooker, R. S., D. J. Cipher, and E. Sekscenski. 2005. Patient satisfaction with physician assistant, nurse practitioner, and physician care: A national survey of Medicare beneficiaries. Journal of Clinical Outcomes Management 12(2):88-92.

17. Melin, A. L., and L. O. Bygren. 1992. Efficacy of the rehabilitation of elderly primary health care patients after short-stay hospital treatment. Medical Care 30(11):1004.

18. Mezey, M., S. G. Burger, H. G. Bloom, A. Bonner, M. Bourbonniere, B. Bowers, J. B. Burl, E. Capezuti, D. Carter, J. Dimant, S. A. Jerro, S. C. Reinhard, and M. Ter Maat. 2005. Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. Journal of the American Geriatrics Society 53(10):1790-1797.

19. AACN (American Association of Colleges of Nursing). 2004. Nurse practitioner and clinical nurse specialist competencies for older adult care. http://www.hartfordign.org/case_study/ Geriatric%20Competencies%20for%20non-GNPs.pdf (accessed February 1, 2008).

20. AACN. 2006. Student enrollment rises in U.S. nursing colleges and universities for the 6th consecutive year. http://www.aacn.nche.edu/06Survey.htm (accessed July 9, 2007).
21. BLS. 2007b. Occupational outlook handbook, 2008-09 edition: Licensed practical and licensed vocational nurses. http://www.bls.gov/oco/ocos102.htm (accessed December 28, 2007).

22. 20-Harrington, C., H. Carrillo, and C. LaCava. 2006. Nursing facilities, staffing, residents and facility deficiencies, 1999 through 2005. http://www.pascenter.org/documents/OSCAR 2005.pdf (accessed January 29, 2008).

23. World Health Organization (WHO), Preventing Chronic Disease: A Vital Investment (Geneva: WHO, 2005).