FUTURE HISTORY

Journal of Gerontology: MEDICAL SCIENCES Copyright 2002 by The Gerontological Society of America
2002, Vol. 57A, No. 7, M438–M441

The Future History of Gerontological Nursing

Mathy Mezey and Terry Fulmer

The John A. Hartford Foundation Institute for Geriatric Nursing, New York University, Steinhardt School of Education,
Division of Nursing, New York.

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Having established an academic and clinical infrastructure, geriatric nursing is well positioned to play a central
role in improving the health of the nation’s older adults now and in the future. Currently, whether working inde-
pendently, in collaborative practice with physicians, or as members of geriatric teams, geriatric nurse practition-
ers and clinical specialists have been shown to improve care to older adults in the community, in hospitals, and
in skilled nursing facilities. Sixty-three master’s programs now prepare advanced practice geriatric nurses. Geri-
atric nurse researchers have contributed to our understanding of the most pressing problems that impact pro-
foundly on the health and quality of life of older adults. Despite these advances, the number of geriatric nurse
specialists remains small, with only 4200 certified specialists and a serious shortage of geriatric nursing faculty.
Geriatric nursing is moving to ensure geriatric competency in all nurses who work with older adults in the fu-
ture. The future should see the benefits of current efforts to infuse geriatric content into baccalaureate programs
that prepare registered nurses, into master’s programs that prepare adult and family nurse practitioners, and
into the day-to-day practice of the nation’s 2.2 million practicing registered nurses.

T HE history of geriatric nursing in the United States is

notable for the scope of its response to the burgeoning
demands of older adults and their families. The American
Nurses Association (ANA) convened its first focus group
on gerontological nursing in 1962; the first gerontological
practice group convened in 1966. In 1968, the Geriatric Di-
vision of the ANA published the first geriatric nursing stan-
dards, followed shortly by ANA certification of the first
gerontological nurses. This flurry of activity coincides with
the attention generated by Titles 18 and 19 of the Social Se-
curity Act, which established Medicare and Medicaid.
Since then, the increased number of older adults, the
changing face of American health care, and substantial
shifts in health policy and funding have helped to shape ge-
riatric nursing education, research, and practice. In this arti-
cle, we focus on the current status of geriatric nursing and
address its future history. Although the ANA emphasizes
the term gerontological nursing for this area of special ex-
pertise and knowledge, the term geriatric nursing is equiva-
lent and will be used interchangeably in this article.
Foundation commitment and support nationally has sub-
stantially shaped the recent history of gerontological nurs-
ing. In 1981, the Robert Wood Johnson Foundation sup-
ported the Teaching Nursing Home to demonstrate patient
and educational outcomes related to collaborations between
academic nursing and nursing homes (1). The Kellogg
Foundation funded a national project to develop geriatric
curriculum for associate degree nursing programs, with an
emphasis on long-term care (2). During the past 25 years,
the John A. Hartford Foundation has supported the aca-
demic preparation, practice, and research capacity of geriat-
ric medicine. Beginning in 1990, the Hartford Foundation
began to invest in geriatric nursing. Foundation funding for
2001 represents a $35 million investment in geriatric nurs-
ing (http://www.gerontologicalnursing.info/). This commit-
ment, which represents the largest funding commitment of
any foundation in nursing, has served to stimulate curricu-
lum reform, the development of academic centers of excel-
lence, and pre- and postdoctoral scholarships, thus position-
ing geriatrics as a substantial area of future research and
practice within nursing.
THE CLINICAL AND EDUCATIONAL PERSPECTIVE
Advanced Practice Geriatric Nurses
For almost 35 years, the overwhelming emphasis in geri-
atric nursing has been to prepare a cadre of advanced prac-
tice geriatric nurse specialists. In 1966, Duke University
started the first gerontological master’s program. Advanced
practice geriatric nurses are registered nurses who have
completed a master’s program to specialize as geriatric
nurse practitioners, geriatric nurse clinical specialists, and
geropsychiatric nurses. These advanced practice geriatric
nurses work in collaboration with geriatric physicians and
social workers to render care to older adults and serve as
faculty to prepare increasingly large numbers of geriatric
nurses. Their practice is recognized through state and pro-
fessional certification, and they are reimbursed by both
Medicaid and Medicare.
Several studies have underscored the national impera-
tive for advanced practice nurses prepared to care for
America’s older adults (3,4). The need for advanced prac-
tice nurses with geriatric skills is particularly dramatic
among the “oldest-old,” those persons 85 and older who
constitute the fastest growing segment of our older popula-
tion and who are most likely to require management of
multiple chronic conditions and functional losses. The ma-
jority of these older adults have a disproportionate number
of untoward acute health events and chronic illnesses that
require primary, acute, and long-term care (5). Normal age
changes and the increased risk of illness associated with
advanced age exacerbate poor health in this group of older
adults. On average, 53% of people 80 and older have one
or more severe disabilities, 79% have at least one chronic
disability, and 36% have moderate or severe memory im-
pairment (5).

M438
 FUTURE OF GERONTOLOGICAL NURSING
In the face of regulatory barriers, and a general antipathy
on the part of health care professionals to geriatrics, ad-
vanced practice geriatric nurses have achieved an impres-
sive record in managing the complex health needs of older
adults. Evidence is strong that advanced practice geriatric
nurses, often as part of geriatric teams, ensure quality care
to older people and significantly improve health outcomes
in ambulatory (6), acute (7), (8), and institutional long-term
care (9–12).
Yet, despite a 30-year effort on the part of academic and
professional nursing organizations (13–16), and substantial
federal support for training, the number of advanced prac-
tice geriatric nurses remains very small. The 63 programs
that prepare advanced geriatric nurses graduate a mean of
three students annually (16,17). Since 1991, only approxi-
mately 4200 nurses nationally have been certified by the
American Nurses Credentialing Center (ANCC) as ad-
vanced practice geriatric nurses (GNPs: 3400; GCNS: 800)
(M. Smolensky, Executive Director, The American Nurses
Credentialing Center, January 2002). Because they are so
few in number, and because they practice predominantly in
institutional long-term care and in urban settings, advanced
practice geriatric nurses exert a minimal impact on the
health care needs of the majority of older adults.
Adult and Family Advanced Practice Nurses
Given the failure to attract large numbers of nurses to the
specialization of geriatrics, during the past few years, there
has evolved a growing appreciation within nursing that
adult and family practice advanced practice nurses represent
an untapped pool of health care providers for older adults.
Currently, approximately 12,500 nurses are ANCC certified
as advanced practice adult practitioners, and 24,400 are ad-
vanced practice nurses certified in family practice (M. Smo-
lensky, Executive Director, The American Nurses Creden-
tialing Center, January 2002).
It is highly likely that the practice of these advanced prac-
tice nurses involves the care for large numbers of older
adults. Older adults’ use of health care services is very high.
They make up 60% of all ambulatory visits, 48% of adult
hospital admissions, 80% of home care visits, and 85% of
all nursing home residents (18). In home care, the fastest
growing area of health care, in 1995, the 5600 Medicare-
certified agencies made more than 38 million visits to 1.6
million Medicare beneficiaries; 52% of these were nursing
visits (19). On any given day, more than 1.7 million older
persons are cared for in 16,700 long-term care facilities.
One in three Americans will spend some time in such a fa-
cility prior to death; 1% of persons aged 65 and older but
19% of persons 85 and older currently reside in long-term
care facilities (20).
The field of geriatrics/gerontology has evolved to the
point where there now exist recognized standards for “best
practice” in care of older adults (6,16,21,22). Nevertheless,
there is general consensus that the health care that most
older people receive fails to adhere to agreed-upon quality
standards (7,23,24).
While lacking definitive data, a cursory review of curric-
ula in programs preparing adult and family advanced prac-
tice nurses suggests that geriatric content and best practices,
M439
for example best practices in relationship to pain manage-
ment and use of physical restraints, have been minimally
addressed. Thus, there are several new initiatives with the
specific goal to introduce concepts of best practice in geriat-
ric care into the adult and family practice nursing educa-
tional curriculum (17). These initiatives include the devel-
opment of nationally recognized competencies in geriatrics
for all programs preparing advanced practice nurses likely
to work with older adults (adult, family, women’s health,
critical care, and psychiatric advanced practice nurses).
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They also include the development of curriculum materials,
ongoing professional education, and a push to encourage the
creation of programs for adult, family, women’s health, crit-
ical care, and psychiatric advanced practice nurses to ac-
quire certification in geriatric nursing as a second credential
to their existing area of specialization.
“Gerontologicalizing” the Practicing Nurse
In addition to focusing on master’s prepared advanced
practice nurses, during the past 5 years, the profession has
slowly embraced a strategy to prepare all practicing nurses
with basic geriatric competencies as a way to ensure that
older adults experience appropriate nursing care. Virtually
all nurses in the course of their careers care for older
adults: providing preventive and wellness programs; help-
ing patients manage multiple chronic conditions and deal
with increased mental and physical frailty; and facilitating
a peaceful death. It is, therefore, imperative that these
nurses have basic competence to deliver care to older
adults.
To date, there have been two initiatives to ensure geriat-
ric competency in the practicing nurse. The first is to en-
sure geriatric competency in all students who graduate
from a nursing program. Nursing schools have only re-
cently begun to include geriatrics in their curricula, and
most still do not have geriatrics as a significant and inte-
gral part (18). The Hartford Institute initially championed
this initiative for geriatric nursing. Working collabora-
tively with the American Association of Colleges of Nurs-
ing, the national organization that accredits schools of
nursing, the Hartford Institute developed geriatric
competencies and curriculum materials for baccalaureate
nursing programs, activities that have now been expanded
through additional support from the Hartford Foundation
(www.hartfordign.org).
The second initiative, which is only now developing, in-
volves preparing all 2.2 million practicing nurses and the
40,000 registered nurses newly licensed each year with
competency in geriatrics. Most new graduates and virtually
all practicing nurses have had inadequate preparation in ge-
riatrics. Practicing nurses receive little continuing education
in geriatrics. It is only recently that the Joint Commission on
the Accreditation of Healthcare Organizations, the accredit-
ing body for hospitals and nursing homes, has required that
their member facilities begin to demonstrate age-specific
competencies of their personnel.
Initial efforts to ensure geriatric competency in the prac-
ticing nurse have focused on the organizations representing
the elite group of professional nurses who have an interest
and expertise in a specific area of nursing, such as oncol-
M440 MEZEY AND FULMER
ogy, emergency room, rehabilitation, and intensive care.
There are 78 nursing specialty associations that collaborate
in a national forum called the Nursing Organization Liaison
Forum (NOLF). NOLF functions as a structure of the Amer-
ican Nurses Association. Eliminating the obvious special-
ties such as pediatrics and midwifery, 60 of these 78 associ-
ations, representing a total of 400,000 nurses, focus on a
care specialty with a direct impact on older adults. The
membership size of these nursing organizations ranges from
several hundred to more than 62,000. Ensuring geriatric
competency in specialty nurses offers an opportunity to
make substantial inroads into “gerontologizing” practicing
nurses. Effort to introduce geriatric competencies has in-
volved presentations and a booth to create a geriatric pres-
ence at national conferences, providing ready-made materi-
als for use in organization newsletters, journals, and web
sites, and creating and/or supporting geriatric focus groups
or special interest group that allows for formalizing a sus-
tained interest in geriatrics (www.hartfordign.org).
GERONTOLOGICAL NURSING: A RESEARCH AND
POLICY PERSPECTIVE
Research productivity is one of the most impressive out-
comes of geriatric nursing during the past 20 years. Often
beginning with small qualitative studies, and substantially
bolstered by funding from the National Institute for Nursing
Research and the National Institute on Aging, geriatric nurs-
ing has made substantial contributions to improved patient
care and to policy decisions that influence the structure in
which care is delivered.
Geriatric nursing research has been influential in chang-
ing the paradigm for the use of physical restraints in nursing
homes and hospitals (25,26), improving the assessment and
management of pressure ulcers (27,28), pioneering im-
provements in assessment and management of urinary in-
continence (29), and ensuring appropriate end-of-life care
(30,31). In nursing homes, nursing research has led in ex-
ploring strategies to improve care for physically and cogni-
tively frail and vulnerable older adults: creating and testing
strategies to improve bathing, feeding, and managing diffi-
cult and disruptive behaviors (32). Nursing research has
been instrumental in identifying outcomes associated with
evolving models of geriatric care, for example the Geriatric
Resource Nurse and Acute Care of the Elderly units in hos-
pitals (33,34), nurse practitioner models in nursing homes
(35), a home visit program for older adults as part of a home
care agency (8), and the use of interdisciplinary teams to
provide geriatric care (36). Nursing research is beginning to
document the relationship between nurse staffing models
and patient outcomes in hospitals (7) and nursing homes
(11,35,37,38), and to document improvements in care that
are attributable to the use of geriatric advanced practice
nurses (10,35,39).
Data from these and other studies have been influential in
changing policy, reimbursement, and regulations. Espe-
cially in nursing homes, these data have changed standards
for the use of physical restraints, influenced efforts to create
higher standards for nurse staffing in nursing homes, and
shown how advance directives can be used to improve end-
of-life care.
PROJECTIONS FOR FUTURE DIRECTIONS
The evidence of the past 30 years suggests that geriatric
nursing will be a force for continued improvements in
care to older adults during the next decade. There is good
evidence that, in the future, older adults are more likely to
be cared for by a nurse who has received special prepara-
tion in geriatrics (40). The movement toward ensuring ge-
riatric competencies for all practicing nurses should ac-
celerate as curriculum revisions take hold and thus ensure
geriatric competency in the future nursing workforce. Ex-
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panded efforts hold promise in increasing the number of
nurses prepared with geriatric specialization above the
current level and ensuring that adult, family, and psychi-
atric advanced practice nurses will complete their aca-
demic programs with a strong preparation in geriatric
nursing. These efforts should also serve to ensure geriat-
ric capacity in nurses working with older patients who
have comorbidity such as heart disease, cancer, and neu-
rological disorders.
The establishment of Centers for Geriatric Nursing Excel-
lence (http://www.gerontologicalnursing.info/) and programs
to support pre- and postdoctoral fellowships in geriatric nurs-
ing (www.hartfordign.org; www.gerontologicalnursing.info)
are instrumental in ensuring a “pipeline” of well-prepared
academic nurses who can sustain programs of geriatric re-
search and educate the next generation of geriatric nursing
leaders. Of special note is the past and current commitment
of geriatric nurses to tackle difficult but exceptionally
meaningful issues that impact profoundly on the health and
quality of life of older adults, for example elder mistreat-
ment (41), the decision-making capacity of cognitively im-
paired elders (42), and pain assessment and management
(43). Continued support from the National Institutes of
Health will be crucial if geriatric research is to continue to
grow and flourish.
There are several areas of geriatric nursing where the
crystal ball is cloudy. The first relates to the role of geriatric
teams generally. While care by geriatric teams has consis-
tently been shown to substantially improve outcomes for
older adults (44), geriatric teams will flourish only in a cli-
mate of improved empirical evidence of academic and clini-
cal support. The second area relates to the involvement of
geriatric nurses in health policy. While they have made in-
roads in influencing health care policy, the voice of geriatric
nurses at the policy table continues to be underrepresented
and undervalued. Several of the new Hartford Foundation-
funded geriatric nursing initiatives are addressing the need
for leadership preparation. The extent to which they capital-
ize on this support will directly influence the effectiveness
of geriatric nurses to shape and direct policy on behalf of
older adults.
Acknowledgments
We express our gratitude to Abraham A. Brody for his assistance in pre-
paring this manuscript.
Address correspondence to Mathy Mezey, EdD, RN, FAAN, Indepen-
dence Foundation Professor of Nursing Education, Director, The John A.
Hartford Foundation Institute for Geriatric Nursing, New York University,
Steinhardt School of Education, Division of Nursing, 246 Greene Street,
New York, NY 10003-6677. E-mail: mathy.mezey@nyu.edu
 FUTURE OF GERONTOLOGICAL NURSING
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Received February 21, 2002
Accepted February 22, 2002