Who will take care of us? Nurses for the elderly in short supply
For the first time in modern American life, a couple will likely spend more time caring for their aging parents than their children. Life expectancy continues to increase, meaning there is a greater chance people will reach their 80s, when disabilities and chronic conditions, such as Parkinson’s disease and heart failure, appear. With smaller families and gray divorce becoming more common, there is a greater chance seniors will age alone, leading to the question, Who will take care of us?
Mennonite College of Nursing (MCN) Associate Professor Brenda Johnson and Professor Mary Dyck are working to answer that question by preparing the next generation of nurses for elder care. The pair are also researching how hospitals are recruiting new graduates and what long-term care facilities can do to make nursing careers there more attractive.
Johnson, who practiced as a gerontological nurse specialist, was the primary caregiver for her parents until they died. Even with her experience and expertise, she found managing their care difficult. “I was constantly trying to help them navigate the health care system—access the help they needed while avoiding the pitfalls of inappropriate treatment.” she said.
“It was exhausting. You’re constantly fighting to find care for them. As a nurse, I was trying to keep them from that next complication.”
Johnson and Dyck are preparing students for working with a population of older adults growing at an exponential rate: The population over the age of 65 is set to double in the next 40 years, and among that group the number with Alzheimer’s disease is expected to triple. Despite these trends, less than 50 percent of baccalaureate nursing programs in the country have a dedicated course in gerontological nursing. Dyck, who is also the college’s associate dean for research and a former nursing home administrator, developed such a course at Illinois State. She described older adults as “the most complicated patients” at least, in part, because illness often presents in a different way in advanced age.
Johnson teaches the course, which has an emphasis on the different presentations of illness. “It is crucial that all clinicians working with older adults recognize, for example, that an older adult is less likely to have a fever with even a serious infection such as pneumonia and more likely have confusion or weakness as the presenting symptom. Potentially reversible problems are missed and outcomes of care are poor when nurses are not using this ‘geriatric lens.’”
Johnson has seen a steady increase in students interested in gerontological nursing, but not as many as she would like. Only about one in five MCN students wants to work with older adults after graduation. Furthermore, these students often still prefer to begin their practice in a hospital setting, not long-term care facilities, which are having difficulty recruiting and retaining qualified nurses.
As Johnson has seen a growing number of students interested in practicing with older adults, she has begun to explore how clear the focus on geriatric services might be to prospective employees as well as to consumers. This past year she collaborated with MCN Professor Myoung Jin Kim and graduate students Emily McMahon and Ali Mojadam on a pilot study that compared the visibility on hospitals’ websites of geriatric services compared with childbirth services.
“The take-home message from this study was that in nearly every category, obstetrical services were more visible than those offered for older adults, which is ironic when you consider the fact that older adults will continue to be the single largest population served by health care systems for the foreseeable future,” Johnson said.
When students tell Johnson they are interested in working with older adults, she encourages them to look for hospitals with the NICHE (Nurses Improving Care for Healthsystem Elders) designation. The NICHE program takes an interdisciplinary, evidence-based approach to improving the quality of care for acutely ill older adults. Many NICHE hospitals have specialized units with specialists in
geriatrics delivering the care—including nurses certified in gerontological nursing.”
However, Johnson and the team found that the NICHE designation was not always very visible on hospitals’ websites. “How can we recruit professionals into it if it’s not visible that there’s a specialization and appreciation for this knowledge? I see it as a chicken or egg situation. I don’t know where the problem starts. Those with the passion and the undergraduate preparation in geriatrics are not necessarily being actively recruited,” she said.
Nursing homes are even less likely to attract the attention of students because they have fewer resources than hospitals for recruitment and continuing education. Opportunities for professional development are slim with bare-bones nursing staffs who cannot leave a unit for continuing education events. Administrative staff may lack leadership experience, which also means fewer opportunities for mentoring.
According to state regulations, directors of assisted living facilities need to be only a licensed practical nurse (LPN) to lead care. That regulation is in conflict with the Illinois Nurse Practice Act that only allows a registered nurse (RN), which requires an associate or a bachelor’s degree, to delegate and lead care. Nursing home regulations require directors of nursing to hold at least the RN license. Dyck’s research has shown that in Central Illinois about 70 percent of directors of nursing in nursing homes have an associate degree only. Since leadership skills are taught in bachelor’s programs, leadership skills may be lacking, and turnover among directors is high, Dyck said.
“What we’re seeing is our directors of nursing and nursing leaders in those communities have never had leadership education in nursing, and then we wonder sometimes why there might be a problem with turnover in staff, why there might be a problem sometimes with the quality,” Dyck said.
The leadership void is not always understood by administration.
“A lot of administrators think a nurse is a nurse is a nurse. We have that in a study we published in 2018. The nurses said the RNs and LPNs did about the same things in their facility,” she said.
Dyck helped revise the Illinois Nurse Practice Act in 2018. Her research reviewed the duties of RNs and LPNs in nursing homes and made recommendations for change.
“We found that quite a few LPNs were doing things that were for RNs only and that RNs weren’t practicing nearly to the top of their scope,” she said. “They weren’t providing what we identified as leadership activities.”
Dyck’s career has been focused on long-term care, as a clinical nurse specialist as well as an administrator. She knows that nursing homes need well-educated, skilled nurses, but also younger staff.
The average age of RNs is 50, with 20 years of experience. Older nurses have difficulty with 12-hour shifts, Dyck said.
“Do I think there’s an issue with staffing with older adults from a workforce area? Yes, and I think it’s going to get much worse,” she said.
Not only is staffing an issue, but nonprofit nursing homes are closing their doors because of a low Medicaid reimbursement rate, creating even fewer options for the elderly.
“It is a real crisis and it’s a crisis people don’t know about because they don’t want to pay attention to the older adults,” Dyck said. “There’s a shortage of people wanting to work with older adults. There needs to be some more innovative work in terms of benefits and residencies for them to develop their skills. I also think we need to advocate for increased Medicaid reimbursement for Illinois nursing homes as the state’s rate of nursing home reimbursement is 49th in the nation. Hopefully, if others besides nurses advocate for increased Medicaid reimbursement for nursing homes, we can start pulling our head out of the sand and increase the quality of care.”