Responding to a nursing mandate in long-term care: A multi-modal pilot curriculum for bachelor of science in nursing students

On September 1, 2023, the Centers for Medicare and Medicaid Services (CMS) released new guidelines for staffing long-term care (LTC) in the U.S. responding to the Executive order from President Biden. The order requires improvement in the quality of care for 1.2 million residents of LTC facilities, most of whom are older adults.¹ These guidelines mandate in-facility presence of registered nurses round-the-clock, seven-days-a-week and enhanced presence of nurse's aides who have training to meet the complex care needs of LTC residents.¹ Expanding the currently inadequate nursing workforce in LTC is critical. Comprehensive review of the literature found that including geriatrics and LTC content in undergraduate nursing students' curriculum through clinical placements effectively enhanced their competence in these content areas.²

We developed a new geriatrics curriculum for Bachelor of Nursing Students (BSN) that included content as the 4Ms of Age Friendly Care coupled with LTC content.³ Learners completed the multi-modal curriculum, which included an online component, at their own pace. In the absence of real patients through clinical placements, interacting with standardized patients (SPs) is another actionable teaching model. Research by the National Council for the State Boards of Nursing found that replacing traditional clinical hours with high-fidelity simulated experiences are effective in nursing curriculum.⁴ After completing our multi-modal curriculum, learners applied the content using virtual SPs. Our program is the first of its kind where use of “virtual SPs” means the SPs were live, but students were interacting with them through a virtual platform. After the interaction students received feedback from the SP and a faculty member who was also observing the interaction through Zoom.

Our new curriculum used multiple modalities including locally and nationally developed web modules on geriatrics topics, myths of aging, advanced care planning, and LTC and videos on dementia and the 4Ms. Students completed the roughly 10-h curriculum at their own pace. Our objectives focused on students defining the 4Ms, applying them to a LTC population, and having exposure to LTC as a potential new career option.

Student evaluation included: (1) pre- and post-knowledge assessment (using the Alzheimer's Disease Knowledge Scale and web-based module questions); (2) attitude assessment (using the Kogan's Attitude Toward Older People Scale and the Four-Domain Sense of Competence in Dementia Care Staff); and (3) skills using four virtual standardized patient scenarios developed by the investigators. Investigators trained SPs on the scenarios. Training was repeated until 80% agreement on checklist completion between the SP and the investigator was achieved. Students were given 20 min to interact with the SPs per scenario, followed by 10 min of feedback provided by both the SP and the faculty observer.

The Biden Administration in late 2023 issued an Executive order taking steps to improve the quality of care in LTC facilities through increasing staffing time provided by nurses and nurse's aides. This legislation will result in the need to train more nursing professionals to provide care. According to Miller et al., the declining quality of care in LTC due to staffing shortages is partially a result of the pandemic. We piloted a new curriculum which is multi-modal in both instruction (e.g., online learning and virtual SPs) and assessment. According to Tirola et al., virtual SPs are especially valuable during personnel and resources shortages. Our pilot shows promise in providing instruction on geriatric content and LTC.

We found significant difference between the pre- and post-scores for all the web-based modules and a marginally significant improvement in positively focused items on the Attitude Toward Older People survey. There was no significant difference between individual pre- and post-Alzheimer's disease knowledge scores and the Professionalism Domain on the Sense of Competence in Dementia Care Staff. Although low number of students and completion rate of attitude surveys are limitations of our study, piloting innovative curriculum about LTC care for nursing students are essential given the rapidly increasing U.S. aging population. We found coupling online educational modalities with virtual SPs showed promising results for BSN education and deserves further evaluation. Students' responses indicated the web-based content was helpful both for providing instruction and feedback. Multi-modal teaching strategies and assessment methods are essential to increase the nursing workforce in an attempt to meet staffing demands in LTC facilities.

Glenda R. Westmoreland: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published. Kathryn I. Frank: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published. Emilie L. Garrison: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published. Qing Tang: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published. Julia Loubeau: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; final approval of the version to be published. Julie Krieger: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; final approval of the version to be published. Sarah Hartman: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; final approval of the version to be published. Sarah Roth: Aquisition of data, or analysis and interpretation of data; draft the article or revising it critically for important intellectual content; final approval of the version to be published. Debra K. Litzelman: Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be published.

No authors have a conflict of interest to report.

This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $4,083,767 with zero percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.