HEALTH POLICY AND SYSTEMS

Hospital Nurses’ Perceptions of the Geriatric Care Environment in One Canadian Health Care Region Jo-Ann Lapointe McKenzie, BScN, MN, RN1 , Audrey A. Blandford, BA2 , Verena H. Menec, PhD3 , Marie Boltz, PhD, RN, CRNP, NHA4 , & Elizabeth Capezuti, PhD, RN, FAAN5 1 Xi Lambda, Chief Nursing Officer, Deer Lodge Centre and WRHA Program Director, Rehab Geriatric Program, Winnipeg, Manitoba, Canada 2 Research Coordinator, Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada 3 Professor, Department of Community Health Sciences and Director, Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada 4 Assistant Professor, College of Nursing, New York University, New York City, USA 5 Dr. John W. Rowe Professor in Successful Aging and Co-director John A. Hartford Foundation Institute for Geriatric Nursing, New York University, College of Nursing, New York City, USA

Key words Hospital nurses, older adults, geriatric care environment, Canada Correspondence Jo-Ann Lapointe McKenzie, Deer Lodge Centre, 2109 Portage Avenue, Winnipeg, Manitoba, R3J 0L3. E-mail: jlapointemckenzie@ deerlodge.mb.ca Accepted January 7, 2011 doi: 10.1111/j.1547-5069.2011.01387.x

Journal of Nursing Scholarship, 2011; 43:2, 181–187.  C 2011 Sigma Theta Tau International

Abstract Purpose: To identify and compare perceptions of the geriatric care environment among nurses in three different urban hospital types in one health authority in a Midwestern Canadian province. Design: The Geriatric Institutional Assessment Profile developed by the Nurses Improving Healthsystem Elders (NICHE) program was administered to staff in eight urban hospitals between 2005 and 2006: two geriatric-chronic care hospitals, four community hospitals, and two tertiary hospitals. The study focused on 1,189 nurses who completed the survey (n = 298 for geriatric-chronic care hospitals; n = 387 for community hospitals, n = 504 for tertiary hospitals). Methods: Analyses focused on items related to the concept of the geriatric nursing practice environment, including a composite measure of overall perceptions and three subscales (institutional values regarding older adults and staff, resource availability, and capacity for collaboration). Nurses’ perceptions of the extent to which facilities supported the provision of aging-sensitive or aging-relevant care to older adults and their families was also examined. Univariate analysis of variance was performed to determine significant group differences among nurses in the three hospital types. Findings: Perceptions of the geriatric nurse practice environment (both in terms of the composite scale and the three subscales) were least positive among nurses in community hospitals relative to the other two hospital types. Perceptions in tertiary hospitals were significantly more positive than those in community hospitals in terms of institutional values and resource availability, albeit not capacity for collaboration. Perceptions were most positive in the geriatric-chronic care hospitals. Perceptions of aging-sensitive care delivery were also less positive in community and tertiary hospitals, relative to geriatricchronic care hospitals; perceptions in community and tertiary hospitals did not differ from each other. Conclusions: In this Canadian study, nurses’ perception of the care environment varied by hospital type, with nurses in community hospitals expressing the most concern and nurses in geriatric-chronic care hospitals being the most positive. This research highlights the importance of the hospital setting in understanding nurses’ ability to provide quality geriatric care. Clinical Relevance: Enhancing the quality of care for older patients requires an understanding of the challenges and obstacles experienced by nurses. Assessing their perceptions of the care environment they work in, therefore, becomes a key issue in targeting policy and programs. 181

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Optimizing care for hospitalized older adults is an important goal, given that the majority of patients in hospitals are older adults and they are the most likely to experience complications. Data from the United States indicates that individuals 65 years of age and over comprise 60% of hospital admissions, represent 48% of hospital days, and compared with other age groups have longer lengths of stay (DeFrances, Hall, & Podgornik, 2005; O’Neill & Barry, 2003; Russo & Elixhauser, 2006). Similar to the United States, older Canadians account for a third of all acute-care hospitalizations and about half of all hospital days, with an average length of stay of nearly 11 days compared with 5 days for patients younger than 65 years (Statistics Canada, 2005). This trend is also evident in the province of Manitoba, the setting of the present study, where individuals 65 years of age and over have been shown to incur 60% of all hospital days (Manitoba Health & Healthy Living, 2007) and 59% of all inpatient costs in the province (Menec, MacWilliam, Soodeen, & Mitchell, 2002). Once admitted to the hospital, older adults are at increased risk for experiencing adverse events (e.g., acute confusion and nosocomial infections), increased length of stay, readmission, and functional decline (Covinsky et al., 2003; Creditor, 1993; Lefevre et al., 1992). Development of elder-friendly care environments is hindered by lack of formal education regarding the specialized nursing needs of older patients (Berman et al., 2005). This lack of gerontological nursing content has been noted in both Canada and the United States (Gilje, Lacey, & Moore, 2007; King, 2004). Specifically, based on a review of gerontological nursing content in Canadian baccalaureate nursing programs, Baumbusch and Andrusyszyn (2002) found that only 8% of clinical hours had a focus on nursing older adults and only 5.5% of students chose geriatrics for their final clinical placement prior to graduation. As the number of older adults increases, the need for well-educated, skilled gerontological nurses will continue to increase (King, 2005). In addition to a lack of specialized geriatric nursing care, shortcomings within the acute care hospital environment in Canada (e.g., staffing issues, physical environment) also have an impact on creating an elderfriendly care environment. Most often, nurses within acute care hospitals focus solely on managing the care required for acute illnesses. This can be a disadvantage to older adults, who are often hospitalized because of an acute episode, but are facing chronic health problems. Strategies are needed to narrow the gap between what older adults need and what the hospital environment offers, including systems and processes to support the needs of professionals working in the hospital environment (Parke & Brand, 2004). These strategies will need to be creative and flexible to deal with fiscal restraint, com182

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peting priorities, and pressure from the public to provide elder-friendly hospital care (Parke & Stevenson, 1999). Research indicates that the organizational and work environment, as well as the organizational supports available, are associated with nursing practice and quality of care (Boltz et al., 2008a; Capuano, Bokovoy, Hitchings, & Houser, 2005; Kim et al., 2009; Mezey et al., 2004, Oelke et al., 2008). In their adaptation of the framework developed by Aiken, Sochalski, & Lake (1997), Boltz and colleagues (2008b) proposed that hospital structural characteristics (e.g., bed size, type of ownership) and nurse characteristics (e.g., demographics, experience in profession) are linked to the geriatric nursing practice environment, which, in turn, relate to geriatric outcomes. Our study is guided by this conceptual framework. One important aspect of the work environment is the type of hospital in which care is provided. The question of whether hospital type, in this case geriatric-chronic, community, and tertiary relate to perceptions of the geriatric nurse practice environment has not yet been examined. Examining perception of the geriatric care environment across different care settings is a first step in determining where change or education is most needed in order to ensure the best quality of care for older adults.

Context of the Present Study Canada has a universal healthcare system, with health care organized and funded at the provincial level. Like other provinces, Manitoba’s healthcare system is regionalized. The mission of Regional Health Authorities is to promote and protect health and well-being by delivering and managing health services (community-based health care, such as home care, hospital care, and longterm care) to individuals living within a geographic area. The Winnipeg Regional Health Authority (WRHA) is the largest region in the province, serving an urban population of just over 700,000. In addition, the WRHA plays an important provincial role by providing healthcare support to nearly half a million Manitobans who live beyond the WRHA boundary requiring the tertiary services and expertise available within the WRHA. Given the universal healthcare system, access to healthcare services, including hospitalization, is provided free of charge to patients. Admission to a specific hospital is based on physician admission privileges, but also specific patient need. Geriatric-chronic care facilities serve patients who have intense rehabilitation and specialized care needs. There are often progressive care plans for these patients, resulting in longer hospital stays. The main focus of geriatric-chronic care facilities is on care for patients 65 years of age and over, even though they serve

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persons of all ages. In terms of staffing, nurses working in geriatric-chronic care facilities are aware they will be caring for an older population, and some training in geriatric care is expected. On the other hand, tertiary sites deal with complex health problems that require expert consultation and management. These hospitals provide care for severe acute episodes (e.g., cardiac surgery) and also function as the primary teaching hospitals in the province. Community hospitals are designed for less complex cases; patients generally have shorter hospital stays. They are on average smaller than geriatric-chronic care and tertiary hospitals. Although tertiary and community hospitals do not have a geriatric focus, the majority of patients are 65 years of age or older. In 2005, the WRHA launched the Elder-Friendly Hospital Initiative (EFHI) in order to increase the capacity to provide the best quality of care to older adults in all hospitals in the region (Winnipeg Regional Health Authority, 2006). To that effect, the region adopted the Nurses Improving Care for Healthsystem Elders (NICHE) program established in the United States, which has been implemented in over 200 hospitals in the United States, Canada, and Europe (www.nicheprogram.org. NICHE has developed and disseminated a “tool kit” of resources and organizational models (Fulmer et al., 2002). An important tool on the path to making hospitals more elder friendly is the assessment of a “baseline” via the Geriatric Institutional Assessment Profile (GIAP) survey (NicheHartford Institute for Geriatric Nursing). Among other issues examined, the GIAP includes a geriatric care environment scale that measures staff perceptions of how the organizational practice environment supports or hinders care delivery provided to older adults and how the care provided reflects age-sensitive principles (Kim et al., 2007). This assessment provides a basis for targeting changes. In sum, the purpose of the present study was to compare perceptions of the geriatric care environment among nurses across three different types of hospitals in the WRHA: two geriatric-chronic hospitals, four community hospitals, and two tertiary hospitals. Across the eight hospitals, there were a total of 5,162 registered nurse (RN) positions: 68% in the two tertiary hospitals, 12% in the two geriatric-chronic care facilities, and 20% in the four community hospitals. The present study adds to the literature in two important ways. There is a paucity of research on perceptions of the geriatric care environment from countries other than the United States. Moreover, as the NICHE approach is increasingly being adopted in other countries (Kim et al., 2007) this study provides a useful basis for hospitals outside as well as in the United States against which to com-

pare their findings. Our study also provides the opportunity to examine perceptions of the geriatric care environment within a universal healthcare system. Previous research has demonstrated differences between Canada and the United States on a variety of quality-of-care indicators, which may, in part, be attributed to differences in healthcare systems (Guyatt et al., 2007; O’Neill & O’Neill, 2008).

Methods Sites and Participants From November 2005 to September 2006, eight of the nine hospitals within the WRHA jurisdiction administered the NICHE GIAP survey (see description below) as part of the WRHA EFHI. All healthcare providers (e.g., nurses, physiotherapists, physicians, healthcare aides) who were likely to come into contact with patients 65 years of age or over were eligible for inclusion in the survey, with one hospital opting to include staff not involved in direct patient care as well (e.g., custodial staff). A total of 7,575 surveys were distributed across the eight sites; 2,750 surveys were completed for an overall response rate of 36.3%. Individual hospital response rates ranged from 21.4% to 78.1%. Five of the eight hospitals had a response rate of over 40%. This study focuses on the 1,189 nurses who completed the GIAP survey (n = 298 in the two geriatric-chronic hospitals, n = 387 in four community hospitals, and n = 504 in the two tertiary hospitals). All these individuals checked off “nurse” or “registered nurse” in response to the survey question “In what position do you spend the majority of your time?” All nurses included in the analysis were professionally trained and licensed to practice in Manitoba. Most nurses indicated having either a diploma in nursing (51.7%) or a baccalaureate in nursing (28.4%) as their highest level of education. The vast majority of nurses (86.5%) were women, with approximately one third between 40 and 49 years of age. On average, these individuals had worked 16.8 years as a nurse and 11.8 years in their current hospital.

Data Collection Data collection at each site was coordinated by an Elder-Friendly Care Initiative Committee; members included clinical nurse specialists, unit or department managers, and physicians. Site committees were responsible for advertising the survey (e.g., flyers, newsletter announcement), distributing the surveys, and providing incentives for completing the surveys (e.g., prize draws, pizza parties). Staff placed completed surveys in drop boxes that were collected by the chairs of the site 183

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committees. Completed surveys were sent to the Centre on Aging, University of Manitoba, for data entry, analysis, and preparation of individualized site reports. As completion of the survey was voluntary and participation in the study implied consent, a consent form was not used. Staff members were not identified by name, and there was no way to identify who had or had not completed a survey. Staff was informed that all surveys were being couriered to the Centre on Aging. Data was stored in compliance with the provincial Personal Health Information Act (PHIA). Ethics approval was obtained from the Education-Nursing Research Ethics Board, University of Manitoba, to conduct additional (secondary) data analysis of the GIAP survey data for the purposes of this study.

The Survey A regional advisory committee, including representatives from all the hospitals within the WRHA, reviewed the NICHE GIAP prior to administration in the hospitals, with the decision made to omit one item that was not deemed relevant to the WRHA context. The GIAP consists of eight major scales and several subscales, which have demonstrated good construct validity and reliability (Abraham et al., 1999; Boltz et al., 2008a, 2008b, 2009; Kim et al., 2007). Reported internal consistency of these scales ranges from α = .66 to α = .93 (Abraham et al., 1999; Kim et al., 2007). Substantial work has gone into determining the psychometric properties of the 28 items pertaining to the geriatric care environment (Abraham et al., 1999; Boltz et al., 2008b; Kim et al., 2007). Factor analysis conducted by Kim and colleagues (2007) resulted in four subscales (institutional values around older adults and staff, capacity for collaboration, resource availability, and agingsensitive care delivery). This four-factor structure did not vary significantly across four groups of RNs working in three different types of hospitals. We first conducted a confirmatory factor analysis to determine if the same factor structure would be evident in our data, given that one item was excluded. This was indeed the case, lending support to the construct validity of the scale and suggesting that the minor changes made to the NICHE GIAP had little effect on the grouping of these items. Following research by Boltz et al. (2008b), we considered the first three subscales as measures of the geriatric nursing practice environment, institutional values regarding older adults and staff, capacity for collaboration, and resource availability. Aging-sensitive care delivery was kept as a separate measure. Specifically, institutional values regarding older adults and staff assesses the perceived organizational support 184

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for staff involvement in decision making, respect for the rights of older adults, as well as support for nurses’ personal growth. Each of the seven items was scored as 1 = strongly disagree to 4 = strongly agree. The subscale score was the sum of these items for those who answered at least three items (Cronbach’s α = .83); higher scores are indicative of a greater level of agreement with these items (a more positive perspective). Capacity for collaboration (e.g., perceptions of use of geriatric protocols, degree of conflict around care of older patients) and resource availability (e.g., perceived staffing, availability of equipment) assess perceived institutional obstacles to geriatric care. Original response categories were reverse coded prior to analysis so that higher scores were indicative of perceptions of less interference (1 = greatly interferes to 3 = does not interfere). Nurses had to answer at least one of the capacity for collaboration items and four or more of the resource availability items to be included in the respective subscales. The Cronbach’s α was .78 for the capacity for collaboration subscale and .89 for the resource availability subscale. A composite measure of the geriatric nurse practice environment was created using all 18 items described above (Cronbach’s α = .90); nurses had to answer 9 of the 18 items to be included in the composite measure. Aging-sensitive care delivery measures the extent to which facilities support the provision of aging-sensitive or aging-relevant care to older adults and their families (e.g., whether staff individualize care, whether there is continuity of care across settings; Kim et al., 2007). These items were scored from 1 = not very satisfied to 3 = very satisfied. Individuals who answered four or more items were included in the scale (Cronbach’s α = .92).

Analysis Data were analyzed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA) software. One-way analysis of variance (ANOVA) was performed to determine significant group differences among the nurses in the three hospital types. The Scheffe´ test was used to identify significant differences in mean scores between each of the three hospital types (SPSS, 1999).

Findings The mean score for the geriatric nurse practice environment composite scale was 39.9 (SD = 7.9; possible range 12–61). For the three subscales, means were 18.9 (SD = 3.5; possible range 3–28) for institutional values regarding older adults and staff; 6.4 (SD = 1.9; possible range 1–9) for capacity for collaboration; and 15.3 (SD = 4.3; possible range 4–24) for resource availability. The mean

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Table. Comparison of Nurse Perceptions of the Geriatric Nurse Practice Environment and Aging-Sensitive Care Delivery Scales by Type of Hospital Mean1 n

Scales Geriatric Nurse Practice Environment Composite Scale Institutional Values Regarding Older Adults and Staff2 Capacity for Collaboration2

1,116 1,150 1,112

Resource Availability

2

1,086 Aging-Sensitive Care Delivery Scale 1 2

1,145

Geriatric/chronic

Community

Tertiary

43.35a (SD = 7.4) 20.26a (SD = 3.4) 6.82a (SD = 1.9) 16.94a (SD = 4.4) 20.81a (SD = 4.4)

37.42b (SD = 7.7) 17.92b (SD = 3.7) 6.14b (SD = 1.8) 13.98b (SD = 3.8) 18.37b (SD = 4.9)

39.73c (SD = 7.6) 18.76c (SD = 3.2) 6.34b (SD = 1.8) 15.27c (SD = 4.2) 18.84b (SD = 4.8)

F 47.56∗ 39.14∗ 10.77∗ 39.06∗ 23.39∗

Means in the same row that do not share subscripts a, b, or c differ at p < .05 on the Scheffe´ test. N differs across scales because of missing values. Subscales that are part of the composite scale. ∗ p < .001.

score for the aging-sensitive care delivery scale was 19.2 (SD = 4.8; possible range 4–27). The one-way ANOVA results indicated that hospital type was significantly associated with nurses’ perceptions of the geriatric nurse practice environment composite scale (F = 47.56, df = 2, p < .001; Table). Post hoc analysis (Scheffe´ tests) further revealed that nurses in geriatric-chronic hospitals had significantly higher mean scores than nurses in community hospitals and nurses in tertiary hospitals. Nurses in tertiary hospitals also had significantly higher mean scores than nurses in community hospitals on the geriatric nurse practice environment scale. This trend continued when examining the subscales, institutional values regarding older adults and staff, capacity for collaboration, and resource availability. The mean scores on these three subscales significantly differed by hospital type (see Table). As with the composite measure, nurses in geriatric-chronic hospitals had significantly higher mean scores compared with nurses in community and tertiary hospitals. Once again, nurses in community hospitals had the lowest mean scores and were significantly different from nurses in tertiary hospitals. Hospital type was also significantly related to the agingsensitive care delivery scale (see Table). Once again, nurses in geriatric-chronic care hospitals had significantly higher mean scores (i.e., were more satisfied) than both nurses in community and tertiary hospitals. However, mean scores did not significantly differ between community hospital and tertiary hospital nurses.

Discussion Although much has been written about elder-friendly hospitals and the need to enhance the care provided to older adults, who constitute the majority of patients in

hospitals, much of the research evidence on the geriatric care environment has emerged from the United States (Boltz et al., 2008b; Kim et al., 2007; Kim et al., 2009). The present study contributes to this literature by focusing on a Canadian (Manitoba) context and, thus, a healthcare system that is organized quite differently. Overall, nurses’ perceptions of the geriatric practice environment clustered around the mid-point of the scales, with a slight tendency toward the positive ends in the case of measures related to aging-sensitive care delivery and capacity for collaboration. This suggests there is considerable room for improvement in providing an optimal care environment and aging-sensitive care, corroborating findings from the United States (Boltz et al., 2008b). Nurses’ perceptions provide key information on which areas should strategically be targeted for improvement. Our findings further indicate nurses’ perceptions of the geriatric nurse practice environment and aging-sensitive care delivery varied by the type of hospital (geriatricchronic care, community, or tertiary) in which they work. In contrast, previous research by Boltz and colleagues (2008a) showed that hospital characteristics (type of hospital ownership, hospital bed size, hospital teaching status) were not significantly associated with perceptions of the geriatric nurse practice environment or aging-sensitive care delivery. This discrepancy in findings suggests that further research is needed to determine exactly what kinds of hospital characteristics impact the nurse practice environment. Nurses in community hospitals were the least positive in their perceptions of the geriatric nurse practice environment; they were even less positive than those of nurses working in tertiary hospitals. This suggests that community hospitals need to be particularly targeted for practice improvements. Why perceptions were least positive in community hospitals cannot be determined from 185

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the present data, but the overall economic pressures that hospitals experience may be one issue at play. In Manitoba, regional health authorities are accountable for the cost of health care in their region. Reducing length of stay in hospitals has become a key issue in trying to reduce health care costs. By definition, community hospitals (and tertiary hospitals) in the WRHA deal with more acute care needs than geriatric-chronic care hospitals. Therefore, the pressure to minimize lengths of stay may be perceived more acutely in these settings and may be perceived as conflicting with the need to provide quality of care for older adults. Relative to tertiary hospitals, community hospitals in the WRHA also have more limited access to consultation support from either geriatric clinical nurse specialists or geriatricians. Our study also highlights the uniqueness of nurses working in geriatric-chronic care hospitals compared with those working in community or tertiary hospitals in terms of their perceptions of the geriatric nurse practice environment. Geriatric-chronic care nurses perceived the geriatric nurse practice environment as more positive compared with both nurses in community or tertiary hospitals, as indicated by higher mean scores on the composite scale as well as each of the three subscales. These findings are not surprising. For example, greater perceived institutional (organizational) commitment to geriatric care would be expected given the mandates of these types of hospitals. Self-selection may also be at play, as nurses who enjoy working with older adults and who may, consequently, have sought enhanced geriatric training may have chosen to work in geriatric-chronic care hospitals. In terms of provision of aging-sensitive care, nurses in geriatric-chronic care hospitals again were more satisfied than their counterparts in community and tertiary hospitals, whereas no difference emerged between community and tertiary hospitals. Previous research has shown that patient outcomes are improved through the promotion of age-sensitive care (Boltz et al., 2008b; Fulmer et al., 2002; Pfaff, 2002). Our findings therefore point to the need for educational activities on the delivery of age-sensitive care, especially within community and tertiary hospitals. A few limitations of the present study must be acknowledged. Although we were able to include a range of hospitals in the present study (eight of nine hospitals in the WRHA), completion of the survey was voluntary. This may have led to response bias with, for example, more dissatisfied than satisfied staff responding. Nevertheless, the size of the sample and the fact that all types of hospitals in the WRHA are represented affords a unique opportunity to examine issues related to elder-friendly care within a universal healthcare system. As a further limitation, more detailed categorization of nurses within hospital type (e.g., by unit) might have provided further 186

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insight and a better understanding of nurses’ perceptions of the geriatric nurse practice environment within a specific context. Lastly, although the study is based on the largest administration of the GIAP survey in Canada, to the best of our knowledge, it is only representative of nurses in one healthcare region (the WRHA) in Manitoba. Whether the results generalize to other regions in Manitoba and to other provinces is a question for future research.

Conclusions and Implications The present study adds to the body of research that addresses the importance of organizational supports in the evaluation of the geriatric nurse practice environment (Boltz et al., 2008a, 2008b; Kim et al., 2007, 2009). The findings indicate that particularly community and tertiary hospitals need to target specific areas of practice for improvement. A structured curriculum delivered in a variety of learning modalities by geriatric experts can then be evaluated using both specific outcome measures of quality care and a repeat of the GIAP. From a program delivery and policy perspective, the findings of the survey provide information on key areas to target. It also suggests the need to collect more specific clinical data that would allow assessment of how changes in the hospital environment impact specific clinical outcomes.

Acknowledgments Funding for this research was provided to the Centre on Aging by the Winnipeg Regional Health Authority. V. Menec holds a Canada Research Chair in Healthy Aging.

Clinical Resource r Nurses Improving Care

for Healthsystem Elders:

www.nicheprogram.org

References Abraham, I. L., Bottrell, M. M., Dash, K. R., Fulmer, T. T., Mezey, M. D., O’Donnell, L., & Vince-Whitman, C. (1999). Profiling care and benchmarking best practice in care of hospitalized elderly: The Geriatric Institutional Assessment Profile. Nursing Clinics of North America, 34(2), 239–255. Aiken, L. H., Sochalski, J., & Lake, E. T. (1997). Studying outcomes of organizational change in health services. Medical Care, 35(11), NS6–NS18. Baumbusch, J. L., & Andrusyszyn, M. (2002). Gerontological content in Canadian baccalaureate nursing programs: Cause for concern? Canadian Journal of Nursing Research, 34(1), 119–129.

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Berman, A., Mezey, M., Kobayashi, M., Fulmer, T., Stanley, J., Thornlow, D., & Rosenfeld, P. (2005). Gerontological nursing content in baccalaureate nursing programs: Comparison of findings from 1997 and 2003. Journal of Professional Nursing, 21(5), 268–275. Boltz, M., Capezuti, E., Bowar-Ferres, S., Norman, R., Secic, M., Kim, H., . . . Fulmer, T. (2008a). Changes in the geriatric care environment associated with NICHE (Nurses Improving Care for Healthsystem Elders). Geriatric Nursing, 29(3), 176–185. Boltz, M., Capezuti, E., Bowar-Ferres, S., Norman, R., Secic, M., Kim, H., . . . Fulmer, T. (2008b). Hospital nurses’ perception of the geriatric nurse practice environment. Journal of Nursing Scholarship, 40(3), 282–289. Boltz, M., Capezuti, E., Kim, H., Fairchild, S., & Secic, M. (2009). Test retest reliability of the Geriatric Institutional Assessment Profile. Clinical Nursing Research, 18(3), 242–252. Capuano, T., Bokovoy, J., Hitchings, K., & Houser, J. (2005). Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital. Health Care Management Review, 30(3), 229–236. Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L., Kresevic, D., . . . Landefeld, C. S. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of the American Geriatric Society, 51, 451–458. Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219–223. DeFrances, C. J., Hall, M. J., & Podgornik, M. N. (2005). 2003 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics, 359, 1–20. Fulmer, T., Mezey, M., Bottrell, M., Abraham, I., Sazant, J., Grossman, S., & Grisham, E. (2002). Nurses Improving Care for Healthsystem Elders (NICHE): Using outcomes and benchmarks for evidence-based practice. Geriatric Nursing, 23(3), 121–127. Gilje, F., Lacey, L., & Moore, C. (2007). Gerontology and geriatric issues and trends in U.S. nursing programs: A national survey. Journal of Professional Nursing, 23(1), 21–29. Guyatt, G., Devereaux, P., Lexchin, J., Stone, S., Yalnizyan, A., Himmelstein, D., . . . Bhatnagar, N. (2007). A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, 1(1). Retrieved from http://www.openmedicine.ca/article/view/8/15 Kim, H., Capezuti, E., Boltz, M., & Fairchild, S. (2009). The nursing practice environment and nurse-perceived quality of geriatric care in hospitals. Western Journal of Nursing Research, 31(4), 480–495. Kim, H., Capezuti, E., Boltz, M., Fairchild, S., Fulmer, T., & Mezey, M. (2007). Factor structure of the geriatric care environment scale. Nursing Research, 56(5), 339–347.

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King, T. (2004). Status and standards of care for older adults. Canadian Nurse, 100(5), 23–26. King, T. (2005). Helping baccalaureate nursing students care for the wellbeing of older adults. International Journal of Nursing Education Scholarship, 2(1), 1–12. Lefevre, F., Feinglass, J., Potts., S., Soglin, L., Martin, G. J., & Webster J. R. (1992). Iatrogenic complications in high-risk, elderly patients. Archives of Internal Medicine, 152, 2074–2080. Manitoba Health and Healthy Living. (2007). Manitoba Health and Healthy Living annual statistics 2006–2007. Retrieved from http://www.gov.mb.ca/health/annstat/index.html Menec, V. H., MacWilliam, L., Soodeen, R. A., & Mitchell, L. (2002). The health and health care use of Manitoba’s seniors: Have they changed over time? Winnipeg, Manitoba, Canada: University of Manitoba, Manitoba Centre for Health Policy. Mezey, M., Kobayashi, M., Grossman, S., Firpo, A., Fulmer, T., & Mitty, E. (2004). Nurses Improving Care to Health System Elders (NICHE): Implementation of best practice models. Journal of Nursing Administration, 34(10), 451–457. NICHE-Hartford Institute for Geriatric Nursing. Geriatric Institutional Assessment Profile (GIAP). Retrieved from http://www.nicheprogram.org/benchmarking Oelke, N., White, D., Besner, J., Doran, D., McGillis Hall, L., & Giovannetti, P. (2008). Nursing workforce utilization: An examination of facilitators and barriers on scope of practice. Nursing Leadership, 21(1), 58–71. O’Neill, G., & Barry, P. (2003). Training physicians in geriatric care: Responding to critical need. Retrieved from http://www. agingsociety.org/agingsociety/pdf/trainging.pdf O’Neill, J. E., & O’Neill, D. M. (2008). Health status, health care and inequality: Canada vs. the U.S. Forum for Health Economics & Policy, 10(1), (Frontiers in Health Policy Research), Article 3. Retrieved from http://www. bepress.com/fhep/10/1/3 Parke, B., & Brand, P. (2004). An elder-friendly hospital: Translating a dream into reality. Nursing Leadership, 17(1), 62–76. Parke, B., & Stevenson, L. (1999). Creating an elder-friendly hospital. Healthcare Management Forum, 12(3), 45–48. Pfaff, J. (2002). The geriatric resource nurse model: A cultural change. Geriatric Nursing, 23(3), 140–144. Russo, C. A., & Elixhauser, A. (2006). Hospitalizations in the elderly population, 2003 (Statistical Brief No. 6). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.hcup-us.ahrq.gov/reports/ statbriefs/sbstatbriefs/sb6.jsp. SPSS. (1999). SPSS base 10.0 applications guide. Chicago, IL: Author. Statistics Canada. (2005). Seniors’ health care use. Health Reports, 16, 33–45, Supplement (Statistics Canada Catalogue 82-003). Winnipeg Regional Health Authority. (2006). Elder-friendly care project charter. Winnipeg, Manitoba, Canada: Winnipeg Regional Health Authority. 187

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