Care Provision for Older Adults: Who Will Provide?

....nearly 6,000 Americans will celebrate a 65^th birthday each day. Ten years from today, the US will have nearly 10,000 people a day turning age 65. And still, too few doctors, nurses and other health professionals receive any formal training in how to provide the best care for older patients (Alliance for Aging Research, 2002, p. 2).

The growing proportion and numbers of older adults in the American population will have a profound impact on all sectors of society, including health care. Currently accounting for 12.4% of the population, by the year 2030 the older U.S. population will double to about 70 million and account for 20% of the population (Administration on Aging, 2002). With few exceptions, a nurse’s typical patient is an older adult, age 65 or older. Older adults account for over 60% of all adult ambulatory visits, 80% of home care visits, 49% of all hospital days, and comprise 85% of all long-term care residents (Centers for Disease Control and Prevention, 2002). Although best geriatric nursing practices have been shown to improve care processes and outcomes of older patients, diffusion of this knowledge into mainstream nursing has been slow. Compounding the lack of geriatric knowledge, there is a growing shortage of registered nurses (RNs). At a time of an increasingly aging population with complex care needs and an increasingly complex technological care environment, the potential lack of skilled RNs is alarming (Kimball & O’Neil, 2002). This article reviews the intersecting forces of the aging population, the nursing workforce shortage, and the lack of geriatric education and training, which will have a profound impact on the health care industry unless steps are taken soon. Recommendations to address these issues are provided.

Aging Population and Impact of Chronic Illnesses

Over the past century, the life expectancy for both men and women has increased dramatically, from 46 years in 1900 to 78 years currently. This increase in longevity has been primarily due to changes in public health, the advent of antibiotics, and advances in medical technology (Administration on Aging, 2002). With longevity, however, comes the increased likelihood for chronic medical conditions (Administration on Aging; Alliance for Aging Research, 2002; Wolff, Starfield, & Anderson, 2002). A large cross-sectional study of over 1,000,000 older adults revealed that 82% had one or more chronic conditions. Moreover, the prevalence of chronic conditions increased with age from 74% for those 65 to 69 years, to 88% for those 85 years or older (Wolff et al.). A significant proportion had multiple conditions: 43% of all older adults had three or more chronic conditions, and 24% had four or more chronic conditions. Associated with chronic illnesses are disabilities. After age 50, the likelihood of an individual being disabled by disease doubles every five to seven years ( Alliance for Aging Research). Of those 65 to 74 years, 26% reported limitations due to chronic conditions; almost half (45%) of those 75 years and older reported one or more limitations due to chronic conditions.

Among acutely ill older adults, hospitalization itself poses a serious threat to the health and functioning of older adults.

Because of these multiple chronic conditions, the older population utilizes a large proportion of the health care services. The mean per capita Medicare expenditure during 1999 was $5,015 (Wolff et al., 2002). As chronic conditions increase, so do Medicare expenditures, from $211 per individual with no chronic conditions to $13,973 among individuals with four or more chronic conditions. Similarly, inpatient hospital utilization rose with the number and types of chronic conditions. Those with one chronic condition were 7.5 times as likely to incur an inpatient admission compared to those with no chronic conditions. Patients with four or more chronic conditions were 99 times as likely to be hospitalized (Wolff et al.).

Nearly two thirds of the Medicare beneficiary population has three or more chronic conditions (Wolff et al., 2002). The interaction of multiple disease states coupled with the psychosocial needs frequently present in this population makes the assessment, planning, and delivery of health care more complex than that of younger cohorts. The care needs of older, acutely ill patients are much more complex and difficult to manage than those of other age groups. Among acutely ill older adults, hospitalization itself poses a serious threat to the health and functioning of older adults. For instance, approximately one-third of hospitalized older adults have a decline in their ability to perform one or more activities of daily living (ADLs) at discharge, and up to 15% of hospitalized older adults develop an adverse drug reaction (Creditor, 1993; Riedinger & Robbins, 1998).

There are a number of perils to the structure and process of health care delivery in the hospital setting (Bowar-Ferres, 2002). The high acuity of patients has turned most tertiary care centers into large intensive care units. The shortened length of stay mandated by third party payors has compressed the delivery of care to a frenetic pace. The reduction of hospital beds in the early 1990s and the growing acuity have created capacity issues of not enough beds, overcrowded emergency departments, and sights of stretchers lined in hallways. Environmental issues of too much stimuli and lack of space for assistive devices (such as walkers and bedside commodes) place the older patient at greater risk for delirium and falls. Insufficient staff is well known with the nursing shortage. Financial constraints from health care revenues have led to low margins and are unlikely to resolve soon, given the current changing and competing priorities in Congress. Information gaps within the health care system are a common complaint among patients and health care providers alike. Inability to access prior records or obtain information from other referring agencies complicate not only the quality, but also the actual delivery of care. Combining these perils with the surge in the older population will only further compound the optimal outcomes from acute care.

Older adults also use the majority of home services. Approximately 69% of home care recipients are age 65 years or older. Forty-five percent of direct care by RNs in the community setting is given to those 65 years and older (Kovner, Mezey, & Harrington, 2002). Nursing home residents are predominantly elderly, accounting for close to 90% of all nursing home occupants (Kovner et al.). The majority of nursing home residents require assistance with activities of daily living and have significant cognitive impairments (Administration on Aging, 2002; Kovner et al.).

Nursing Workforce Shortage

Two factors of the nursing workforce are impacting the delivery of care to older adults, both currently and in the near future. Specifically, these factors are shortages of RNs, non-licensed nursing personnel, and nursing faculty, along with an aging nursing workforce. There have been a number of reports on the recent shortage of RNs (Kimball & O’Neil, 2002). Multiple interacting factors account for this RN shortage, including increased complexity of patient care; dropping enrollments in schools of nursing; lower compensation as compared to other career choices; low job satisfaction; and multiple alternative careers for women (Kimball & O’Neil; Scanlon, 2001; Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000).

Increased complexity of patient care increases the demand for nurses with specialty training, such as critical care and emergency departments (Scanlon, 2001). Increased technology in all settings has increased the demand for a higher skill mix of RNs. Moreover, the expansion of care delivery to community, ambulatory, and long-term care settings has increased both job opportunities and demand for nurses (Scanlon).

Surveys have been conducted annually on enrollment into baccalaureate schools of nursing. Schools of nursing have experienced an overall decreased enrollment of 21% spanning six consecutive years, from 1995 through 2000 (American Association of Colleges of Nursing [AACN], 2002b). While last year’s enrollment in baccalaureate programs increased 3.7% over the previous year, it was still lower than enrollment figures prior to 1995 and insufficient to meet current demands (AACN, 2002b).

Job dissatisfaction may play a critical role in determining the extent of future nurse shortages.

Job dissatisfaction may play a critical role in determining the extent of future nurse shortages.

Indeed, job dissatisfaction is a primary reason cited for nurse retention problems for hospitals as well as nursing homes (Scanlon, 2001). There is a disturbing indication that job dissatisfaction among nurses is high. Aiken and associates (2001) surveyed nurses in five countries and found that over 40% reported job dissatisfaction. Surveyed nurses consistently reported perceived hospital nurse staffing levels that were inadequate to provide safe care, leading to increased pressure to accomplish work, need for overtime, and stress-related illnesses. Another survey found that half of currently employed nurses were considering leaving the health care field for reasons other than retirement (Scanlon).

While shortages have occurred in the past, this current shortage is particularly worrisome since 49% of all RNs are baby boomers (Buerhaus, Staiger, & Auerbach, 2000). Nurses start withdrawing from employment at 55 years of age (Minnick, 2000). Thus, between 2005 and 2010, the withdrawal of baby boomer RNs will have a profound impact on U.S. health care (Buerhaus et al.; Minnick; Spratley et al., 2000). The younger retirement age of nurses as compared to the general workforce is due to a variety of factors, including financial and family issues, and the heavy physical demands of the profession (Berliner & Ginzberg, 2002). Besides retirement, the aging of the RN workforce has another important implication for employers. In 2000, the average age of hospital nurses was 41.8 years, 45.3 years for community nurses, and 49.4 years for faculty (Spratley et al.). By 2010, more than 40% of RNs will be older than 50 years (Buerhaus et al.). Older RNs are more likely to suffer back, neck, and foot injuries, and have a reduced capacity to perform physical tasks as compared to younger RNs (Buerhaus et al.).

The shortage of nurse aides is also at a critical level. There are already reports of 100% turnover rates among nurse aides in nursing home settings (Scanlon, 2001). With the aging of the population, the demand for nurse aides is expected to rise dramatically; indeed, nurse aide jobs increased 40% from 1988 to 1998 (Scanlon). The traditional individual who fills the nurse aide role is a woman between the ages of 20 to 54 years; yet nursee aide numbers are expected to increase by only 9% between 2000 and 2030. Somewhat similar to factors affecting nurse retention, the rapid turnover of nurse aides is due to low wages, difficult working conditions, and fewer benefits compared to other service entry workers (Scanlon). The workload for nurse aides is particularly heavy. Also, nurse aides have the highest rate of workplace injury,13 injuries per 100 employees, as compared to the construction industry with 8 injuries per 100 employees (Scanlon).

Low staffing levels of nurses and nurse aides have already been linked to poorer quality of care and outcomes. In a cross-sectional study involving 10,184 staff nurses and 232,342 general, orthopedic, and vascular surgery patients, Aiken, Clarke, Sloane, Sochalski, and Silber (2002) found an association between increased patient mortality and lower nurse staffing levels. In a large, multi-state sample of hospitals, Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky (2002) found that a higher proportion of nursing care provided by RNs and a greater number of hours of care by RNs per day was associated with better care for hospitalized patients. A higher proportion of hours of care per day by RNs was associated with shorter length of stay; lower rates of urinary tract infections, pneumonia, gastrointestinal bleeding and shock; and a lower rate of cardiac arrest among medical patients. Among surgical patients, a higher proportion of care by RNs was associated with lower rates of urinary tract infections and death from shock or cardiac arrest (Needleman et al.). Low nurse aide staffing has also been shown to impair the quality of care; 54% of surveyed facilities do not meet the minimum threshold of 2.0 hours per resident day (Scanlon, 2001).

Compounding the nursing workforce shortage is the growing nursing faculty shortage.

Compounding the nursing workforce shortage is the growing nursing faculty shortage. Last fall, 39% of the schools of nursing cited faculty shortages as a reason for not accepting applicants (AACN, 2002a). A number of factors contribute to the faculty shortage. First, few nurses obtain advanced degrees. Doctorally prepared nurses, most of whom work in schools of nursing, comprise only 0.6% of the nursing field (Spratley et al., 2000). Master’s prepared nurses, who conduct the bulk of clinical education, comprise only 9.6% of the general nurse population. Additionally, as a group, nursing faculty are older than the rest of the nursing population with a mean age of 49.4 years. Doctorally prepared faculty holding the ranks of professor, associate professor, and assistant professor had median ages of 56.3 years, 53.8 years, and 50.4 years, respectively (AACN, 2002a; Spratley et al.). Because of their older age, 41% of faculty in baccalaureate and higher programs are expected to retire by 2005; among associate degree programs, 24% are expected to retire by 2005 (AACN, 2002a). Third, economics also account for the nursing faculty shortage. Master’s prepared faculty can command up to $25,000 more per year working in service settings as compared to colleges (AACN, 2002a; Armstrong, 2002). Last, similar to the entry-level nurse, there are fewer graduations occurring from master’s and doctoral programs. Graduations from master’s programs have dropped 3.1% and graduations from doctoral programs decreased 11.1% (AACN, 2002a).

Lack of Geriatric Education and Training

A body of knowledge exists on care of older adults

A body of knowledge exists on care of older adults across the continuum of care settings, but this knowledge has not necessarily been transmitted into basic nursing programs.

across the continuum of care settings, but this knowledge has not necessarily been transmitted into basic nursing programs. Although nurses who are in non-obstetric, non-pediatric practices will provide care to a predominantly older population, only 23% of baccalaureate nursing programs nationwide have a required course in geriatric nursing (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). Only thirty baccalaureate nursing programs (4%) met all the criteria for an exemplary geriatrics education (Kovner et al., 2002). Thus, most practicing nurses have limited preparation to care for elders in any setting: long-term, acute care, community, or rehabilitation.

One of the major reasons for insufficient geriatric nursing content is lack of qualified faculty to teach geriatrics (Kovner et al., 2002; Rosenfeld et al., 1999; Strumpf, Wollman, & Mezey, 1993). Of the surveyed schools of nursing, only 42% had a full-time faculty specializing in geriatrics and only 20% reported part-time faculty with a geriatric specialty. Not only is there a lack of doctorally prepared faculty in geriatrics, there is also a lack of qualified advanced practice nurses (APNs). Nationally, the number of geriatric APNs remains small, with only 5,700 nurses certified as geriatric nurse practitioners or geriatric clinical nurse specialists (Kovner et al.). Kovner and colleagues reported that there are only fifty-four master’s programs and forty post-master’s programs that prepare advance practice nurses in geriatrics in the United States. Thus, there are few nurses with specialized training to provide care to older adults or to provide ongoing clinical training for entry-level professional nurses.

Suggestions for the Future

The aging of the baby boomers and nursing workforce, the nursing shortage, and the lack of geriatric knowledge and training among nurses are on a collision course to impact the delivery and quality of health care for the elderly. A number of suggestions have been made to address the multiple issues, either singly or in combination, including:

• Focus on the work environment
• Address the ergonomics of the work environment to facilitate delivery of care to an increasingly dependent patient population
• Promote a positive image of nursing and geriatric nursing in particular
• Provide opportunities for advancement in the service setting and academic setting
• Enhance access to nursing education in general
• Provide education and training in geriatrics to all entry-level nurses
• Develop leadership in geriatric nursing at advanced practice and doctoral levels through federal and state funding initiatives
• Increase education and training of the existing nursing workforce
• Offer financial incentives to organizations and agencies to provide geriatric care
• Use accrediting and regulatory agencies to strengthen the guidelines and regulations for training in geriatric care

(AACN, 2001, 2002a; Alliance for Aging Research, 2002; American Hospital Association, 2002; Armstrong, 2002; Berliner & Ginzberg, 2002; Buerhaus, et al., 2000; Joint Commission on Accreditation of Healthcare Organizations, 2002; Kimball & O’Neil, 2002; Kovner et al., 2002; Scanlon, 2001). The recent passage of the Nurse Reinvestment Act, while not a panacea, addresses several of these issues by funding grants to facilities that retain experienced nurses and develop best practices, grants to enhance education in geriatrics, financial incentives to students who agree to a nurse faculty position after graduation, and public service announcements that promote the positive image of nursing to a diverse population (Donley et al., 2002). Examples of several of the above-mentioned suggestions are provided below.

Work Environment

There are aspects of the work environment that can negatively affect

Providing nurse managers with the behaviors needed for high performance can have a positive impact on the immediate work environment by improving job satisfaction.

nurses’ job satisfaction that can be addressed without requiring an increase in the number of RNs. For instance, a strong correlate of job satisfaction among staff nurses is the type of leadership exhibited by the nurse manager (Cullen, 1999). The ability to build a team and enhance collaboration among the members of a unit is an essential skill of a nurse manager. Yet few nurse managers are provided the skills and training to be an effective leader (Nursing Leadership Academy, 2002). Providing nurse managers with the behaviors needed for high performance can have a positive impact on the immediate work environment by improving job satisfaction.

Ergonomics

Addressing ergonomics in the work environment does require capital resources, which may be limited at this time of shrinking resources and revenues. Nevertheless, addressing the physical aspects of delivering care is important. A growing number of companies offer equipment to facilitate delivery of care that promotes both patient and employee safety. Examples include beds with motors for ease in transportation of patients; transport boards that require only one person to transfer a patient from bed to cart; and patient lifts built into ceiling tracks to facilitate transfer from bed to commode or chair, and to facilitate rehabilitation efforts for patients with unsteady gaits.

Nursing Image

National and regional campaigns have assisted in showing the nursing profession in a positive light. For example, Johnson & Johnson, a major manufacturer of health care products, has launched the highly visible Campaign for Nursing’s Future (Johnson & Johnson, 2002). The Campaign for Nursing’s Future provides scholarships for nursing students, scholarships for nurse educators, television advertising to celebrate nurses, a web site for those interested in pursuing a nursing career, and recruitment posters and brochures for high schools and middle schools. An example at a local level includes a half hour television special, Medical Miracles. Nurses: Celebrating Our Heroes, which showcased nursing at the Cleveland Clinic Foundation (2002). The show resulted in a number of chat room inquiries following the show from those interested in pursuing nursing as a career.

Delivery of Care Models

The shortage of registered nurses mandates that nursing leaders in both service and academia re-examine models of care and processes in the delivery of care. Change in the skill mix of nursing personnel is unavoidable at this time. Examining ways that non-licensed personnel can perform non-nursing functions to enhance nurses’ ability to deliver care is paramount. Focus groups conducted at the Cleveland Clinic Foundation, a 1000-bed tertiary care center, revealed that nurses in all service areas were frustrated with the time spent in accessing equipment and supplies (Kuhar, Spears, Miller, Ulreich, & Mion, in press). A new role, the Equipment Technician, who maintains equipment in working order and ensures that unit-based and room-based supplies are kept stocked, was created. Evaluation of the efficacy of the role revealed that nurses were pleased with the additional support personnel and that equipment and supplies were no longer an issue.

Academe-Service Partnerships

Last, it would behoove nurses from service sectors and academic settings

It would behoove nurses from service sectors and academic settings to collaborate on initiatives to address...the best practices and systems for delivery of care.

to collaborate on initiatives to address not only the current knowledge and skills needed by nurses to practice in today’s environment, but also the best practices and systems for the delivery of care. There are a number of barriers to collaboration, however. Historically, schools of nursing moved into university and college settings and away from service settings to promote nursing as a profession and as a discipline (Dean & Lee, 1995; Sullinger & Ostmoe, 1998). Distancing academe from service has had a downside, however, by increasing the difficulty of clinical teaching and conducting clinical research. The logistics of negotiating contracts, facilitating student learning, and conducting research are made more complicated by geographic distances, philosophical differences, and at times, competing goals (Dean & Lee). It is not uncommon for faculty and students to perceive they are being tolerated or are unwelcome guests by personnel at clinical sites. Moreover, given the nursing profession’s history, nurse educators in colleges and universities often consider direct partnerships with service settings as difficult (Sullinger & Ostmoe).

Despite the barriers to collaborative arrangements between service agencies and schools of nursing, this is a critical time to join resources. One of the strategies necessary for improving quality of nursing care in any setting is the development and implementation of model practice systems at the provider level (Reinhard & Stone, 2001). Such model systems imply not only attention to the design of workable quality improvement programs, but also built-in mechanisms for sharing with others the lessons learned from systematic experimentation. When there are few resources for quality improvement, the costs may be affordable when shared among multiple entities (Reinhard & Stone). It follows that the benefits should be shared as well. Nursing leaders in the academic and service settings need to come forward together, else there is the danger that others will shape nursing’s future.

Summary

This article reviewed the intersecting forces of the aging population, the nursing workforce shortage, and the lack of geriatric education and training, all of which will profoundly impact the health care industry unless steps are taken soon to address the situation. Suggestions to alleviate the gravity of this collision by addressing areas such as the work environment, ergonomics, nursing image, delivery of care models, and academe-service partnerships have been discussed. The recently funded Nurse Reinvestment Act will provide some funding to address the issues considered in this article. However, the situation remains grave. More is needed to provide the elderly with the care they need, and will continue to need, in the years ahead.

Author

Lorraine C. Mion, PhD, RN
e-mail: lmion@metrohealth.org

Lorraine C. Mion, PhD, RN, received her undergraduate degree from St. John College, Cleveland, OH, and her graduate and doctoral degrees from Case Western Reserve University. Specializing in geriatric nursing for over 20 years, Dr. Mion has been actively involved in clinical research and practice, primarily in the acute care setting. She has authored over 50 peer review articles, several book chapters and has received National Institutes of Health and foundation grants examining geriatric nursing practices.

Armstrong, J.D., Jr. (2002, November). Addressing the nursing faculty shortage in Florida. Presentation to the SREB Council on Collegiate Education for Nursing. Retrieved January 18, 2003, from www.sreb.org/programs/nursing/presentations/addressing_the_nursing_faculty_
shortage_in_florida.ppt

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