Career Focus Options Q&A:
How About Geriatric Nursing?
Lisette Hilton

As a student nurse, there’s a good chance that your parents are part of the baby boomer generation, a huge population of people who are moving into their elder years. This affects nursing in two ways: Nurses will be caring for increasing numbers of elderly patients, and large numbers of nurses, who are in their 40s, will be retiring.

It’s easy to see why geriatric nurses are and will continue to be in high demand.

For nurses, geriatrics is a particularly challenging and exciting career choice. It often involves combining biological, psychological, and social changes associated with aging. And unlike in the acute care setting, nurses in geriatric-centered environments often build long-term relationships with their clients and clients’ families.

Nursing Spectrum recently asked Valerie Cotter, CRNP, MSN, to tell readers what she thinks geriatric nursing is all about. Cotter is interm director of the adult health and gerontology nurse practitioner programs, University of Pennsylvania School of Nursing, and an associate fellow os the Hartford Center of Geriatric Nursing Excellence.

NS: Would you describe geriatric nursing?

VC: Geriatric nursing is not just taking care of older people and having that experience with older adults; it’s really learning what makes older adults special and what is unique about their healthcare needs.

For example, it involves learning about their common illnesses and what we call “atypical presentations.” When older adults become sick and have multiple medical problems and are on many medications, they often do not present with the typical signs and symptoms that a younger person would. They might experience more “geriatric” syndromes, like incontinence, falls, or changes in mental status, and those might be their only presenting symptoms of underlying acute medical problems.

Gerontological nurses also need to understand the functional needs of older adults. What is their ability to live in their own homes, to drive, use public transportation, take medications, cook, manage their houses, do laundry, use the phone, groom themselves, walk, and eat? Having a basic functional assessment of the older adult gives you a strong indication that there is an underlying acute medical problem or acute exacerbation of a chronic problem, when you see abrupt changes in their functional abilities.

NS: Are student nurses today more exposed to courses in geriatrics than in the past?

VC: Yes. There is … a strong need now for nurses who are prepared in their academic programs to care for older adults, whether they practice in acute care in the hospital, in community-based settings, outpatient clinics, or long-term care facilities.

At the baccalaureate level, many schools of nursing are integrating the gerontological nursing content in courses and clinical experiences. Some schools of nursing also offer elective courses, specifically in geriatric nursing for undergraduate students. We have an elective course that I teach called “Living with Dementia.” It’s an opportunity for undergraduate nurses to learn more about the care of older adults with dementia, go out to a nursing facility, work with a patient and a family, and become exposed to the field.

NS: What is the role of RNs in the long-term care facility?

VC: Nurses that work in long-term care have quite a responsibility because there are so few professional nurses in long-term care. They are responsible for assessment of residents. (We call patients ‘residents’ in long-term care.) These assessments are usually much more detailed than in acute care because there are maybe one or two professional nurses in the setting as compared to a hospital, where there are many more registered nurses. So, their assessment skills need to be very adept at identifying acute medical problems of older people. They also work hand-in-hand with the nurses’ aides, other interdisciplinary staff, and families.

NS: Where else are these specialty trained nurses in demand?

VC: We would talk about long-term care as a continuum (from the highest to lowest skill level). There are nursing homes with subacute care units, where patients can be on ventilators, intravenous therapy, and feeding tubes. These are high-tech skilled units within nursing facilities. Next are the traditional long-term care nursing facilities, followed by assisted living facilities. Nurses working in personal care, which is usually a lower level of nursing care that is required for people who are more independent in the activities of daily living, might be involved in overseeing things like medication management and meal preparation. Personal care services are usually in long-term care facilities that offer multiple levels of care for adults.

Adult day care centers are also an area where professional nurses are working. RNs are usually charged with oversight of the care of people who coming into adult day care facilities.

Home care has really expanded for RNs and nurse practitioners because older adults prefer to stay in their homes. We need nurses with the gerontological skill sets to work in outpatient clinics, too.

NS: What are the opportunities for nurses with advanced training in geriatric?

VC: We’re in desperate need of more advanced practice nurses who want to have clinical careers in geriatric nursing, functioning as nurse practitioners in direct care with older adults and families, in clinics, home care, hospital-based settings, and long-term care settings. There are only about 2,000 certified gerontological nurse practitioners in the U.S. We need many more to provide direct clinical care to older adults and be leaders and mentors for baccalaureate nurses and other nurses who do not have this special skill set.

The jobs are just tremendous for advanced practice nurses with a master’s degree in nursing and a specialization in gerontological nursing, either as nurse practitioners or clinical nurse specialists.

Nurse practitioners function as clinical care providers. We have direct Medicare reimbursement to provide that care. So, you’re seeing many more nurse practitioners going out into collaborative practices with physicians or other nurse practitioners and opening their own businesses in home care and specialty practices.

NS: What about at the doctoral level?

VC: At the doctorate level, there is also a huge need for geriatric nurses. Recent studies have demonstrated that we desperately need more nursing educators because nursing faculty are retiring, and we need nurses prepared at the doctoral level to design and carry out nursing research on older adults. … we have limited information about what the care needs for older adults are.

NS: What would you say are the characteristics a nurse needs to be successful as a geriatric nurse?

VC: You have to like working with older adults and their families. You obviously have to be smart because you’re in leadership and mentorship positions, where you’re not only providing care to fairly complicated patients but are also directing and coordinating that care with other healthcare providers.

NS: What are the drawbacks and benefits of the career?

VC: It’s hard for me to think about the drawbacks because I believe in it so much.

In gerontological nursing, you have a long, rich career ahead of you regardless of what level you’re at in nursing. I think gerontological nursing is a great choice because there are so many education and career opportunities ahead.

[Being able to develop relationships with patients and families] is why I like being a nurse practitioner in an outpatient setting. I want to see the effects of my nursing interventions … and be able to follow people over time and see that my nursing interventions make a difference.

NS: Do you have advice for student nurses who want to get into this field at the RN level?

VC: One of the things that I recommend to many people … is to seek out gerontological nursing leaders and spend the day or half a day with them. See what they do with patients and families, other nurses, and physicians. I think spending time with someone who loves what they do as a gerontological nurse helps you to appreciate all that is involved in caring for an older adult. That’s different than if you were to go with a nurse who sees a lot of older people but might not be trained or have the educational focus as a geriatric nurse.

NS: Are there any myths about this career?

VC: Yes. Sometimes people say to me: Isn’t it depressing working with older adults? Or they think that you can’t do anything for frail older adults. Those things are misconceptions, and they can lead the nurse and patient and family into such negative attitudes about themselves and their healthcare.

I make it clear (I’m a nurse practitioner at the Memory Disorders Clinic here at the University of Pennsylvania) that our patients and families know that there is always something that can be done for these individuals, and there is always hope.

NS: Do you have an experience that stands out as exemplifying what it’s like to work with older adults?

VC: A patient and her husband came to our memory disorders clinic. She recognized some cognitive changes and was concerned about whether they were normal aging or significant cognitive impairment.

This woman was diagnosed with Alzheimer’s by the physician and I who collaborate. I think what made a difference in their ability to adjust to that new diagnosis was our recognition of what the diagnosis means to them as a couple. It wasn’t just making the medical diagnosis, but sitting down with them and explaining how it might affect their lives; for example, driving, making financial decisions, or her bridge playing.

I’ve seen a big change — especially in her husband, who is more forthcoming in talking about her illness. In the beginning, it was the son who brought her to the visits, not her husband. Through all of this work with them, now the husband comes to every single visit. He’s involved in her medication management. He has become much more educated and more in tune with her functional needs, and he’s has taken on this new role more willingly.

Lisette Hilton is a freelance healthcare reporter, specializing in covering local, national, and worldwide news for nurses, pharmacists, physicians, and other allied health professionals.