NCM- 114

CARE OF OLDER ADULTS

MODULE 4:
CORE ELEMENTS OF EVIDENCE-
BASED GERONTOLOGICAL NURSING
PRACTICE AND ETHICO-LEGAL
CONSIDERATIONS

BSN 3H2
The specialty of gerontological nursing was not always a
popular or well-respected area of practice. However, over
the past few decades, the specialty has experienced
profound growth and has benefited from societal
recognition of the importance of the older segment of the
population. Nurses have many opportunities to play
significant roles in the care of the aging population today
and to shape the future of gerontological nursing.

LEARNING OBJECTIVES
AFTER READING THIS CHAPTER, YOU SHOULD BE
ABLE TO:

1 . Describe the importance of

evidence-based practice in
gerontological nursing.
2. I dentify standards used in
gerontological nursing
practice.
3 . List principles guiding
gerontological nursing
practice.
4 . Discuss major roles for
gerontological nurses.

BSN 3H2
Binwag, Precious Joy Y.
Buhong, Brigitte A.
Cafongtan, Karylle L.
Cancesio, Charlene Angel O.
Carrao, Samuel B. Jr.
Castillo, Louela Grace E.
Chamos,Chamie lyn K.
Cosente Prestina Jian-Gayle G.
Daiwey, Shantal Andrea
Dayao, Nehemia I.

CARE OF OLDER ADULTS

 CHAPTER IV:
CORE ELEMENTS OF GERONTOLOGICAL NURSING PRACTICE
SOME OF THESE CORE ELEMENTS INCLUDE EVIDENCE-BASED PRACTICE AND
STANDARDS AND PRINCIPLES OF GERONTOLOGICAL NURSING.

EVIDENCE-BASED PRACTICE
relies on the synthesis and analysis of available information from
research.
Meta-analysis- is a process of analyzing and compiling the results
of published research studies on a specific topic this process
combines the results of many small studies to allow more
significant conclusions to be made.
cost-analysis reporting, cost-related data are gathered on
outcomes to make comparisons. Performance also can be
compared with best practices or industry averages through a
process of benchmarking.

STANDARDS
Professional nursing practice is guided by standards. Standards
reflect the level and expectations of care that are desired and serve
as a model against which practice can be judged. Thus, standards
serve to both guide and evaluate nursing practice.

Practice standards describe the appropriate therapeutic health and

well-being of gerontological nurses to facilitate the older person’s
health, recovery, and/or well-being and comfort. “The primary
purpose of having standards is to provide direction for professional
practice in order to promote competent, safe and ethical service for
clients”

Standards arise from a variety of sources. State and federal

regulations outline minimum standards of practice for various
healthcare workers (e.g., nurse practice acts) and agencies (e.g.,
nursing homes). The Joint Commission has developed standards for
various clinical settings that strive to describe the maximum
attainable performance levels. The ANA Scope and Standards of
Practice for Gerontological Nursing are the only standards developed
by and for gerontological nurses. Nurses must regularly evaluate their
actual practices against all standards governing their practice areas
to ensure their actions reflect the highest quality care possible.

ANA Standards of Practice for Gerontological Nursing

STANDARD 1. ASSESSMENT
The gerontological nurse collects comprehensive data
pertinent to the older adult’s physical and mental health or
situation.
STANDARD 2. DIAGNOSIS
The gerontological nurse analyzes the assessment data to
determine the diagnoses or issues.
STANDARD 3. OUTCOME IDENTIFICATION
The gerontological nurse identifies expected outcomes for a
plan individualized to the older adult or situation.
STANDARD 4. PLANNING
The gerontological nurse develops a plan to attain expected
outcomes.
STANDARD 5. IMPLEMENTATION
T he gerontological nurse implements the identified plan.

STANDARD 5A: COORDINATION OF CARE- the gerontological nurse

coordinates care delivery.
STANDARD 5B: HEALTH TEACHING AND HEALTH PROMOTION- the
gerontological registered nurse employs strategies to promote
health and a safe environment.
STANDARD 5C: CONSULTATION- t he gerontological advanced
practice registered nurse provides consultation to influence the
identified plan, enhance the abilities of others, and effect change.
STANDARD 5D: PRESCRIPTIVE AUTHORITY AND TREATMENT- t he
gerontological advanced practice registered nurse uses prescriptive
authority, procedures, referrals, treatments, and therapies in
accordance with state and federal laws and regulations.

STANDARD 6. EVALUATION
T he gerontological nurse evaluates the older adult’s progress
toward attainment of expected outcomes .

COMPETENCIES
some basic competencies of the gerontological nurse include the
ability to:
1 . Differentiate normal from abnormal findings in the older adult
2 . Assess the older adult’s physical, emotional, mental, social, and
spiritual status and function
3. Engage the older adult in all aspects of care to the maximum
extent possible
4. Provide information and education on a level and in a language
appropriate for the individual
5. I ndividualize care planning and implementation of the plan
6. I dentify and reduce risks
7 . Empower the older adult to exercise maximum decision-making
8. I dentify and respect preferences arising from the older adult’s
culture, language, race, gender, sexual preference, lifestyle,
experiences, and roles
9. Assist the older adult in evaluating, deciding, locating, and
transitioning to environments that fulfill living and care needs
10. Advocate for and protect the rights of the older person
11 . F acilitate discussion of and honor advance directives

PRINCIPLES
scientific data regarding theories, life adjustments, normal aging, and
pathophysiology of aging are combined with selected information
from psychology, sociology, biology, and other physical and social
sciences to develop nursing principles.

Nursing principles are those proven facts or widely accepted theories

that guide nursing actions. Professional nurses are responsible for
using these principles as the foundation for nursing practice and
ensuring through educational and managerial means that other
caregivers use a sound knowledge base.
PRINCIPLES OF GERONTOLOGICAL NURSING PRACTICE
Agi ng: A Natural Process
Every living organism begins aging from the time of conception. The
process of maturing or aging helps the individual achieve the level of
cellular, organ, and system function necessary for the accomplishment of
l ife tasks. Constantly and continuously, every cell of every organism ages.
Despite the normality and naturalness of this experience, many people
approach aging as though it were a pathologic experience.
For example, commonly heard comments associate aging with: “looking
gray and wrinkled” “losing one’s intellectual function” “becoming sick
and frail” “obtaining little satisfaction from life” “returning to child-like
behavior” “being useless” These are hardly valid descriptions of the
outcomes of aging for most people.
Aging is not a crippling disease; even with limitations that could be
imposed by pathologies of late life, opportunities for usefulness,
fulfillment, and joy are readily present. A realistic understanding of the
aging process can promote a positive attitude toward old age.

Factors I nfl uenci ng the Aging Process

Heredity, nutrition, health status, life experiences, environment, act ivity,
and stress produce unique effects in each individual. Among the variety
of factors either known or hypothesized to affect the usual pattern of
aging, inherited factors are believed by some researchers to determine
the rate of aging.
Malnourishment can hasten the ill effects of the aging process, as can
exposure to environmental toxins, diseases, and stress. In contrast,
mental, physical, and social activity can reduce the rate and degree of
declining function with age.

THE NURSING PROCESS FRAMEWORK

The nursing process provides a systematic approach to the delivery of
nursing care and integrates a wide range of knowledge and skills. The
scope of nursing includes more than following a medical order or
performing an isolated task; the nursing process involves a holistic
approach to individuals and the care they require. The unique
physiologic, psychological, social, and spiritual challenges of older adults
are considered in every phase of the nursing process.

Common Needs
Core needs that promote health and optimum quality of life for all
patients are:
Physiological balance: respiration, circulation, nutrition, hydration,
elimination, movement, rest, comfort, immunity, and risk reduction
Connection: familial, relational, societal, cultural, environmental,
spiritual, and self
Gratification: purpose, pleasure, and dignity

Through self-care practices, people usually perform activities

independently and voluntarily to meet these life requirements. When an
unusual circumstance interferes with an individual’s ability to meet these
demands, nursing intervention could be warranted.
Optimal Health and Wholeness
One can view aging as the process of realizing one’s humanness, wholeness,
and unique identity in an ever-changing world. In late life, people achieve a
sense of personhood that allows them to demonstrate individuality and
move toward self-actualization. By doing so, they are able to experience
harmony with their inner and external environment, realize their self-worth,
enjoy full and deep social relationships, achieve a sense of purpose, and
develop the many facets of their being. Gerontological nurses play an
important role in promoting health and helping people achieve wholeness.
Within the framework of the self-care theory,

nursing actions toward this goal are:

Strengthening the individual’s self-care capacity
Eliminating or minimizing self-care limitations
Providing direct services by acting for, doing for, or assisting the
individual when demands cannot be met independently

GERONTOLOGICAL NURSING ROLES

1 . Healer - In the healer role, the gerontological nurse recognizes that most
human beings value health, are responsible and active participants in
their health maintenance and illness management, and desire harmony
and wholeness with their environment. A holistic approach is essential,
recognizing that older individuals must be viewed in the context of their
biological, emotional, social, cultural, and spiritual elements.
2 . Caregiver -In this role, gerontological nurses use gerontological theory in
the conscientious application of the nursing process to the care of older
adults. Inhe rent in this role is the active participation of older adults and
their significant others and promotion of the highest degree of self-care.
This is especially significant in that older adults who are ill and disabled
are at risk for having decisions made and actions taken for them—in the
interest of “providing care,” “efficiency,” and “best interest”—that rob
them of their existing independence.
3 . Educator - Areas in which gerontological nurses can educate others
include normal aging, pathophysiology, geriatric pharmacology, health
promotion, and available resources. With the d iversity and complexities
of health insurance plans, an important area for consumer education is
teaching older adults how to interpret and compare various plans to
enable them to make informed decisions. Essential to the educator role
is effective communication involving listening, interacting, clarifying,
coaching, validating, and evaluating. The nurse’s educator role also
surfaces during routine nurse–patient interactions. The nurse educates
the patient to address knowledge deficits identified during the
assessment process. New medications, treatments, and choices create
the need for teaching to ensure the patient has the knowledge and skill
to competently make decisions and engage in care.
4. Advocate - nurses can advocate to facilitate a community’s or other
group’s efforts to effect change and achieve benefits for older adults and
to promote gerontological nursing, including new and expanded roles of
nurses in this specialty.
5 . Innovator- . As an innovator, the gerontological nurse assumes an
inquisitive style, making conscious decisions and efforts to experiment
for an end result of improved gerontological practice. This requires the
nurse to be willing to think “out of the box” and take risks associated
with traveling down new roads, transforming visions into reality.
 ADVANCED PRACTICE NURSING ROLES
Advanced practice roles include:
Geriatric nurse practitioners
Geriatric nurse clinical specialists, and
Geropsychiatric nurse clinicians

Most of these roles require the completion of a master’s degree at a

minimum. There is strong evidence that nurses in advanced practice roles
make a significant difference to the care of older adults. Gerontological
nurse practitioners and clinical nurse specialists have been shown to
improve the quality and reduce the cost of care for older persons in a
variety of settings, including hospitals, nursing homes, and ambulatory
care. The clear positive impact on the health and well-being of older adults
should encourage gerontological nurses to pursue these types of advanced
practice roles and to encourage the employment of these advanced
practitioners in their clinical settings.
 CHAPTER V:
ETHICO-LEGAL CONSIDERATION
Ethical principle- Fundamental propositions pertaining to moral practices, beliefs, and
standards of individuals and groups. Derived from our beliefs and values. Find their
foundation in philosophy, religion, and culture and find their expression in personal and
familiar choices and expectations.

Ethical design making- driven by moral reasoning, and our judgment about right,
wrong, good, and bad are influenced by our beliefs about what types of behavior or
conditions in life are desirable or valuable.
“Moral courage is the ability of not being afraid to stand up for one’s core values and ethical
obligations”

Power of attorney- requested by healthcare agencies, can be helpful when the patient
lacks decision-making capacity yet important treatment decisions need to be made.
NOTE: treatment decisions should not be made without consideration of ethical
principles.

Conflict and Dilemma

Conflict is a situation in which there are opposing or indomitable needs, views or
demands.

3 types:
1. Moral distress- occurs when the person believes he or she knows the right thing to do
but is limited in doing so by organizational or societal constraints.
2. Moral uncertainty- the state in which a person is unsure what the moral problem is or
which moral principles or values apply.
3. Moral dilemma- arises when two or more moral principles apply that support mutually
inconsistent actions.
A true dilemma occurs when it appears there are no morally acceptable options. An
important component of ethical behavior is moral sensitivity, or the ability to identify a
moral problem and how our decisions and actions may affect others.

Moral Principles and the Nurse-Patient Relationship

Moral principles are incorporated into the professional code of ethics. The professional-
patient relationship is fiduciary in nature. The term fiduciary is derived from the Latin
word Federe, to trust. Fiduciaries hold something in trust for another. In the case of
health care, the nurse holds in trust the health and well-being of the patient. This is due
to the fact of the patient’s illness and infirmity, lack of medical knowledge and expertise,
and dependence on healthcare professionals to gain access to services, all creating a
state of vulnerability for the patient.

Beneficence and Nonmaleficence

Doing good (beneficence) and avoiding harm (nonmaleficence) are integral to health
care. Nurses must always act to promote the good of patients, and never act, or fail to act,
such that harm results. Failure to rescue is one measure of the effectiveness of healthcare
facilities in rescuing a patient from a complication versus preventing one. There are many
reasons for failure to rescue, ranging from issues as simple as educational background,
inexperience, and lack of knowledge to the more complex such as attitudes toward work,
staffing patterns, and resource allocation.
Advocacy
The term advocate comes from the Latin word advocare to call, to voice, or to
plead the case for another. Provision 3 of the Code of Ethics describes the meaning
of advocacy in nursing as protecting the rights, health, and safety of the patient.

Confidentiality
Confidentiality, maintaining privacy of information, not only is an expectation of
ethics but also is protected under the law in the Health Insurance Portability and
Accountability Act (HIPAA). Ethics requires that nurses, as advocates for patients
and out of respect for them, educate patients about their rights under HIPAA,
protect patient privacy, and share information with others only as permitted by the
patient or required by law.

Fidelity
Fidelity refers to keeping promises or being true to another and being faithful to
established agreements, commitments, and responsibilities.

Veracity
Trust depends on truthfulness; thus, veracity, or truth-telling, is an essential moral
principle in the nurse-patient relationship.

Justice
Justice refers to fairness, equitableness, and appropriateness of an action or
situation given what is due or owed to persons.

Autonomy
According to Provision 1 of the Code of Ethics, what is owed to every person is
respect for their inherent dignity, worth, unique attributes, and human rights. One
of those rights is autonomy, the right to self-governance, to make one’s own
choices and decisions.

Ways to Facilitate Autonomy:

Encourage completion of advance directives
Provide patient-centered care
Provide appropriate education and training to patients and their family
Ensure consents and refusals are truly informed
Support and educate patients about their rights
Stay informed of regulatory guidelines and laws related to the elderly
Provide feedback to legislators developing laws that affect the elderly
Know how to assist patients to access resources and navigate insurance and the
healthcare system.
Informed consent
Informed consent means that the person clearly understands the choices offered.
In exercising the right to self-determination, the patient has a right to be given
accurate, complete, and understandable information in a manner that allows the
person to make a prudent decision on his or her own behalf.
Elements of Informed Consent
1. Adequate disclosure of information
a. Disease process (diagnosis in understandable terms)
b. Prognosis
c. Nature and purpose of proposed treatment or procedure
d. Potential benefits and risks of proposed treatment or procedure
e. Reasonable alternative treatments or procedures and their potential benefits and
risks
f. Likely effect of no treatment or procedure
2. Decisional capacity of the patient
3. Patient comprehension of the information
4. Voluntariness of the patient (free from coercion or undue influence)
5. Consent of the patient

Clinical Assessment of Decision-Making Capacity

1. Ability to understand relevant information
2. Ability to appreciate the current situation and its consequences
3. Ability to reason or manipulate information rationally
4. Ability to communicate a choice
If the patient demonstrates satisfactory response in all four areas, the patient is said to
be “decisional.”

Quality and Sanctity of Life

Quality of life, or one’s personal perception of conditions of life and the degree of
acceptability of such conditions, and to the sanctity of life, or the ultimate value of
life itself as sacred and inviolable and the right to live. Quality of life is a perception
based on personal values and beliefs

Patient’s Right
Patient rights are considered basic to human life, and each person is entitled to
them on a legal, moral, or ethical basis.

10 Rights of Patient
1. Right Patient
2. Right Medication
3. Right Route
4. Right Dosage
5. Right Time
6. Right to Refuse
7. Right Knowledge and Understanding
8. Right Questions or Challenges
9. Right Advice
10. Right Response
Advance Directives and Living Wills
The most fundamental patient right is the right to decide. The Patient Self-
Determination Act of 1990 was enacted to reduce the risk that life would be
shortened or prolonged against the wishes of the individual. Following the belief
that each person has a fundamental right to decide (autonomy), this law requires
that patients are provided the opportunity to express their preferences regarding
life-saving or life-sustaining care.
Decisions regarding life-saving or life-sustaining care are recorded in legal
documents known as advance directives. Advance directives describe actions to
be taken in a situation in which the patient is no longer able to provide informed
consent. Living wills are alternative documents that direct preferences for end-of-
life care issues, providing an “if . . . then. . .” plan. They often include what type of
care to provide and whether resuscitation measures should be taken.
Similar to advanced directives are the physician orders for life-sustaining
treatment (POLST), which are intended for those who do not want to be
resuscitated in an emergency.

Durable Power of Attorney

A durable power of attorney for health care is a legal document designating an
alternative decision-maker in the event the person is incapacitated, a patient may
designate a close friend with a durable power of attorney, superseding the
designation of immediate family members in decision-making in a situation in
which the patient is incapacitated.
The use of a durable power of attorney can decrease conflicts between family
members and allows the designated decision-maker to perform in roles
negotiated in advance with the patient

Competence
Competency refers to one’s mental clarity and appropriateness for decision-
making based on a mental status examination. Competence must be present for
persons to exercise autonomy and their right to decide.

Guardianship
Legal guardianship or conservatorship is the legal appointment of a person to
make decisions on behalf of a person who has been found by the court to be
incapable of making his or her own decisions.
Conservatorship gives the guardian authority regarding financial issues, but not
medical decisions.
Sources of Law
Constitutional law is the supreme law in the United States and takes precedence
over state and local laws. These laws govern federal and state governments,
corporations, and society and guarantee individual rights such as privacy, freedom
of speech, and the right to equal protection.
Statutory laws are ones enacted by federal, state, and local legislation and may
include such things as reporting abuse or communicable diseases.
Administrative laws include ones that originate from administrative agencies,
including state boards of nursing that enforce the state’s Nurse Practice Act.
Common law, sometimes called case law, is based on prior decisions of the court
and provides historical references that may be used during the argument of a case
in court or during settlement negotiations.

Assisted Suicide
Another ethical issue of self-determination and autonomy is that of assisted
suicide.
The ANA published a position statement on assisted suicide in 1994 that still
applies today, stating that it is a violation of the Code of Ethics for Nurses. Instead,
it suggests that nurses focus on providing competent, comprehensive, and
compassionate end-of-life care.

Oregon enacted the Death with Dignity Act in 1997 to allow terminally ill residents of
Oregon to use voluntary self-administration of lethal medications to end their lives.
These medications are expressly prescribed by physicians for this purpose. The law
applies only to mentally competent adults who must:

Provide written documentation of their intentions

Be diagnosed as terminally ill
Participate in a prescribed waiting period
Take the prescribed medication themselves medications must be taken orally

The Death with Dignity Act specifically disallows lethal injection, mercy killing, or
active euthanasia and protects those who participate in the process from liability and
criminal prosecution (Oregon Department of Human Services, 1997).
Ethics in Practice
The Code of Ethics recognizes the vital importance of a nurse’s moral integrity.
“Nurses have a right and a duty to act according to their personal and professional
values and to accept compromise only if reaching a compromise preserves the
nurse’s moral integrity and does not jeopardize the dignity or well-being of the
nurse or others”.

Medical Errors
The failure to complete the intended plan of action or implementation of the
wrong plan to achieve an intended outcome. Other experts characterized medical
errors as deviations from the standard care process that may or may not result in
patient injury.
Negligence is the deviation of accepted practice, a wrongful act, or failure to act by
a healthcare professional, usually due to a lack of knowledge or skill or poor
judgment in the application of the knowledge and skill.

Conflict of Interest
A conflict of interest arises in situations in which a person who has a duty to act for
the benefit of another exploit that relationship for some kind of personal benefit.
Provision 2 of the Code of Ethics, that the nurse’s primary commitment is to the
patient, so, the referral should be made to the facility that could best meet the
needs of the patient, not the one that could best meet the needs of the nurse.