A hospital stay often increases confusion and anxiety in patients with Alzheimer's disease or dementia, complicating the care of their primary diagnosis and potentially lengthening their stay. With an aging population, acute care hospitals are seeing more elderly patients, increasing the need for nurses competent in geriatrics and gerontology.

One hospital is focusing on dementia patients' needs through nurse training and environmental changes. Glen Cove hospital in New York, part of the North Shore-Long Island Jewish Health System, now has more nurses qualified in Alzheimer's care than any other acute care facility

The idea to improve care of the Alzheimer's and dementia population came out of a joint meeting with representatives from local nursing homes, says Susan Kwiatek, associate executive director for patient services at Glen Cove. The community hospital serves three nursing homes and several assisted living facilities.

"Average life expectancy has gone up and we're seeing more and more patients who are elderly and have Alzheimer's or dementia. We wanted to create a continuum of care in the best interest of patients," says Kwiatek. "We wanted to ensure a safe and comfortable environment, and also the respect and dignity of our patents."

With the guidance and assistance of the Alzheimer's Foundation of America, the hospital trained its geriatric-unit nurses and patient care associates how to understand and care for Alzheimer's and dementia patients.

Nurses received two days of education on topics ranging from signs and symptoms of Alzheimer's to how to handle those symptoms and they became qualified as dementia care specialists. PCAs received one day of training and became qualified as dementia care providers.

Elaine Evangelou Soto, nurse manager of the geriatric unit, says the behavior of Alzheimer's patients can be challenging to understand or manage if caregivers do not understand the disease. For example, patients tend to be very fixed and repetitive in their actions and thoughts. One technique the staff learned was that giving a patient a stack of towels to fold can be soothing for the patient.

"Once we received education, it made us more aware of what to look for," says Evangelou Soto. "Now we see a calmer patient. We see a patient who isn't as frightened. We are able to focus more on primary diagnoses, rather than on our patient's behavior."

The hospital also made change to the physical environment to benefit their patients. Rooms have been painted a soothing pastel pink and lighting has been made less obtrusive.

Evangelou Soto explains that prior to the training, nurses were always worried about Alzheimer's and dementia patients' tendency to leave their beds and wander. Through education, they came to understand that patients like to feel they're at home and can walk around at will. So the hospital purchased a roam alert system and now patients who are able can walk the unit at will. A wristband device alerts staff when a patient nears an exit or the perimeter of the unit and an alarm sounds if an exit or perimeter is breached.

"It allows patients the freedom to walk around, and nurses don't have to worry that patients will leave the unit," says Kwiatek. "Creating a soothing environment is key. Alzheimer's patients are habitual. If you bring them into an unfamiliar place, it creates a lot of anxiety. So everything we did, all our strategies were to reduce anxiety: Not to have light that was too reflective, not to restrict them from walking because we were afraid they'd leave the unit, giving them activities that are repetitive and make them comfortable. Now it's a calmer and more soothing environment for patients and staff. We provide better care of the patients."

The training and environmental changes required only a small investment by the organization which Kwiatek says will benefit all patients. She wants to expand the training to emergency department staff. "It would be beneficial for them to understand how to interact with Alzheimer's patients and keep them calm," says Kwiatek. "Especially in the hustle and bustle of the day in the emergency room."

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What's the best way to train new graduate nurses? Ten hospitals will give you 10 different answers. Every organization has its own system to move new nurses through orientation quickly and successfully.

Phoenix-based Banner Health System found itself asking that question last year, says Carol Cheney, MS, Banner's director of simulation and innovation.

"We did an audit and [found that] all units trained in different ways," says Cheney. "We wondered who produces the better nurse? And no one had an answer."

The question came up as Banner Health was opening a state-of-the-art simulated medical center, where the health system will send new nurses in the Arizona region for training.

The center is the lynchpin for the whole project. Banner has operated a simulation center since 2006, which quickly outgrew its allotted space. When Banner's Mesa Hospital moved to a new building, the health system turned the empty hospital into a sophisticated simulation training center that is now used by all its hospitals in Arizona.

The training center could pass for a real hospital. It includes a 20-bed ED, 18-bed med-surg unit, 14-bed ICU, and two ORs. It's filled with high- and low-tech simulation devices and virtual training, and there are plans to add virtual avatars to facilitate behavioral health training.

All new nurses, whether experienced or new graduates, pass through the center after a brief time at their home hospitals to receive facility-specific orientation.

Cheney and her colleagues examined orientation throughout Banner to see what everyone was doing, what needed to be included in orientation, what was required by regulation, and what problems were common in all hospitals.

"We created comprehensive curricula surrounding these topics," says Cheney. "We double checked all polices and procedure guidelines against AHRQ, IHI, so we could bring forward the best evidence-based practice standards."

The resulting orientation at the simulated medical center combines skills training and scenario training. Nurses are put through four-hour scenarios set in the department in which they will work. If they are in the ICU, they'll get an ICU setting with a one- to two-patient ratio.

"The real goal is to immerse them in that environment—on a somewhat simplistic level, we're not trying to scare them—to show them the reality of the unit they will be on," says Cheney.

The training is more interesting for new graduate nurses, as it allows them to experience life on their new unit. "And the beauty is that their patients are essentially plastic," says Cheney.

Facilitators set the scenario and provide coaching and guidance specific to that new nurse. When scenarios are completed, new nurses receive debriefing and talk through the experience. "We do it in a non-punitive way," Cheney says. "We don't say 'Susie you didn't do this.' What we'll do is talk about the patients and what was happening with the patients."

The scenarios let new nurses practice patient care in a safe environment and makes their time with preceptors on their real-life unit more productive. "They don't want new nurses' time with preceptors to be spent learning tasks, such as how to hook up an IV pump, which can be done in the simulation lab," says Cheney. "Time with a preceptor should be an opportunity to develop critical thinking skills and focus on learning clinically-advanced knowledge."

Cheney can create a report on each new graduate and his or her skills and competence. "Orientation used to be really arbitrary," she says. "Now we're saying, 'let's not look at time [spent in orientation]. Let's look at competence.'"

Report summaries identifying new nurses' competence are given to the trainees, their managers, preceptors, and educators, allowing them to individualize training and know which nurses are ready for a greater patient load and which nurses are struggling.

Cheney continues to refine the training. "We're able to see 'where do people make their errors? Are they procedural errors or are they decision making errors?'" she says.

I touched a nerve last week when I asked if we still need Nurses Week. Judging from the emails and comments I received, the answer is an emphatic yes.

My role as devil's advocate annoyed some readers, who argued that nurses deserve recognition for their hard work and contribution to positive patient outcomes. I agree. Too often, as I argued, Nurses Week is applied as a salve; one week of recognition for 51 weeks of being under-valued and under-appreciated.

One senior nursing leader told me she was upset when she first read the article. As she thought about it, however, she changed her mind.

"I was upset because there's truth to it," says Marcia Donlon, vice president, Medical Center, and CNO at Holy Family Memorial in Manitowoc, WI. Donlon told me about the work her organization has done to strengthen nursing professionalism.

"For many years, nurses haven't felt empowered," says Donlon. "They were always being told what they can't do, rather than what they can do. Now our nurses feel empowered."

Donlon says that empowerment is demonstrated at through the work of shared decision-making councils—including performance improvement and professional development—that represent not only the hospital, but all the settings across the system, including home care and clinics.

Donlon says the celebrations on Thursday are proof of the organization's support for the professionalism of its nurses. "The fact is we're recognizing nurses' responsibility for being accountable and being empowered," she says.

One former CNO wrote of her struggles to recognize quality care, which did not resonate with the c-suite:

Bravo! As a former CNO, I always felt that Nurses Week celebrations were patronizing spectacles to "keep the ladies happy." Yes, I subscribed to the hoopla, but I would have much preferred recognition programs that rewarded objective improvements resulting from professional nursing interventions . . . to convince the C-suite that significant financial incentives recognizing exceptional care and quality improvement carried more weight than the perfunctory annual raise, was a major hurdle. Nothing has really changed over the years - the archaic structure of the hospitals governance system still exists; physicians are still being paid for questionable care even while the hospital reimbursement is denied; and rather than reining in inappropriate, ineffectual and non-contributing physician-generated clinical expenses, nurses are among the first to be laid off when revenue shortfalls puts the hospital at financial risk. And we still paternalistically pat the heads of the nursing staff to keep them happy and to say thank you.

—Stefani

Another reader made a connection between Nurses Week and Black History month:

While it would be nice not to need Nurses Week anymore (like not needing Black History month), it is still one time when attention is given to the backbone of the healthcare industry.

—Shari

Several readers made the point that Nurses Week provides a vehicle for media discussion of the role of nursing. If you ever wanted to be published in your hometown paper, Nurses Week is a good hook to get an editor's attention.

There are many members of the public—my own family included—that still do not know enough about the importance of nursing. Part of the reason that nursing week is fantastic is that it allows for discussion and media coverage of the VAST amount of work that nurses do. I'm always excited to see the different work nurses are doing and how they are improving the health of people in all sorts of ways.

—@rdjfraser

Indeed, many people wrote to tell me their organizations use the week to hold nursing research symposiums or bring in expert speakers for continuing education activities.

Nurse Week, like other observances and holidays, is what you make of it. Don't throw out the week, just because some organizations are not evolved and do not recognize and value their nursing staff. I can understand how someone with 10 patients would not appreciate the hypocrisy, and I would surmise that a phony nurse week celebration is the least of that facilities issues. Many hospitals celebrate the week with symposiums and other non-patronizing activities.

—ejohnson

I even received a very touching piece from a communication director at a hospital who did not understand the importance of the caring side of nursing until he himself needed care. You can read his article in this week's NurseLeaders Forum.

As you kick off your celebrations on Thursday, please keep the emails coming and let me know what Nurses Week means to you.

Christy Wade became nurse manager of the emergency department at Jersey City Medical Center two and a half years ago and faced a problem shared with EDs around the country: too many patients and too little space.

In 2009, the urban, level two trauma center saw 77,000 total visits in a space designed for 50,000. The high volume resulted in wait times averaging 3-4 hours, frequent need for diversion, and more than 6% of patients leaving without being seen.

Wade and her colleagues—all Six Sigma certified—searched for ED bottlenecks and ways to remove them. The interdisciplinary team included representatives from every area that interacts with the ED, such as housekeeping, radiology, etc. They instituted changes, including a new approach to observation patients, that have reduced wait times to an average of 30 minutes, and decreased hours on divert to zero. Last month less than 1.5% of patients left without being seen.

When they started the project, the ED began to use an EDIMS computer documentation system, which allowed the Six Sigma team to collate necessary data. "We could pull data in such a way that we could see where our bottlenecks were," says Wade. "We could see where we needed to focus for throughput. One of biggest problems was that we just didn't have enough space."

The team changed the way the ED uses it space. A small room that was being used as a chest pain observation room was converted to space for six or more observation patients.

"The room had two cardiac monitors, two beds. It was not the best use of space," says Wade. "So we removed the stretchers and lined the room with big comfortable treatment chairs."

Now patients who have been seen in the ED and who are under observation or are waiting for something fairly simple can relax in one of the treatment chairs, watching a flatscreen TV, rather than taking up an entire cubicle.

"Let's say someone just needs blood work," says Wade. "They're too sick to go over to our fast track area, but not sick enough to take up a bed. Now they can sit in these comfortable Barcalounger things and watch TV. It frees up valuable stretcher space for acute patients."

The room still houses two beds during quiet times in the ED, but around 11 a.m., when the ED starts to see more patients, the room is quickly converted with the treatment chairs to accommodate more patients. Wade notes the room still contains a stretcher in case a physician needs to reexamine a patient.

Dividers have been added to treatment cubicles for times when the ED gets even busier. "We have fairly big stretchers, so we took two stretcher spaces—two cubicles—and put dividers in, so can make a two cubicle space into three at busy times. And we can quickly convert back when needed," Wade says.

The computer documentation system allows Wade and the organization to keep close eyes on throughput and anticipate when they will need to extend high-capacity hours.

Wade says the changes have increased satisfaction of both staff and patients. "The word is getting out that waiting is decreasing, so our volume is increasing," says Wade. "And we're still able to cope with it. [We recently] had the busiest day in the history of our hospital."