Originally Published in Nursing Leadership, 22(3) : 1–4 October 2009
Much to my surprise, which in and of itself is surprising, I keep getting older. I have studied aging, done research on older people and talked and written about it, but magically, I thought it wouldn't strike me: the wrinkles, the spots, the sags, the bags, the inability to recall a name or a noun when I need it. Fortunately, I am healthy and have not required much in the way of healthcare. But I have to say that my relentless aging scares me because it may, at some point, include the need for nursing care. Let me begin by saying there are many nurses out there providing compassionate, informed care to older patients across the healthcare sectors. Unfortunately, my own experience in working with older people in long-term care facilities and the experiences that friends and colleagues are having with their older relatives, usually parents, tell me there are not enough of these excellent nurses – and that infuriates me. The care that too many nurses are delivering to old and very old patients is not acceptable. It seems that when it comes to older people, too often the care has gone out of nursing care.
I don't think it's necessary to repeat the statistics about our aging population. Look in the mirror. Every day, each of us – and the population as a whole – is aging. The only way to escape growing old is to die young. Between public health improvements, better diets, greater interest in and attention to health-promoting behaviours, advances in medical care and the care delivered by nurses during illness episodes, many more Canadians are living to advanced old age and staying healthy until they reach their older years. Consequently, and something we should all celebrate, most people who require healthcare are older, and many are very old. Because of advanced age and disease or system breakdown, many, and probably most, of these people are vulnerable. They need expert and tender, loving nursing care. Somehow, we can accept and deliver this for children, but too many nurses are not delivering the equivalent quality of care to their older and very old patients. I'm scared because that's me in the near future. And it's every one of you in the future, and it's our parents and other family and friends now. I don't want to have to have a family member with me to protect me from the nursing staff or to provide the nursing care I require but am not receiving. But this is the situation that is occurring too often now.
There are excellent long-term care homes where the staff are knowledgeable and expert in the care their residents require, where they appreciate that it is the nurses' responsibility to bring texture and pleasure to their residents' days and where the registered nurses act as resources and helpful, supportive colleagues to the healthcare aides and practical nurses. But there are not enough of them. There is not enough expert knowledge about the care that frail, vulnerable, cognitively impaired residents require, and there are too few nursing staff who embrace the fact that they are responsible for the quality of daily living of their residents. In acute care, there are units that take pride in the expertise of their nursing staff when it comes to caring for older patients and the patients' families, and where patients feel valued and worthy of attention and care. While this situation should be universal, it does not occur frequently enough.
Why is this so? The explanations are many, and all make some contribution: insufficient knowledge about aging and how to meet the needs of older people; lack of understanding of cognitive impairment and how to work with people with varying degrees of impairment; lack of appreciation that the way an older patient experiences his or her day is a nursing responsibility; frustration because of insufficient time to meet patients' needs; lack of familiarity with research that points to effective interventions for a range of problems and challenges; an absence of role models; little, or at least insufficient, support in the work setting from nurses in managerial or educational roles, or a lack of availability of such nurses; lack of interest in and desire to work with older people ("this is not what I entered nursing to do!"); and too many families making too many demands for the number of time-challenged, available nurses.
Despite this myriad of reasons, I believe they boil down to two fundamental problems: the pervasive lack of expertise (knowledge and skills) related to aging and how to care for older people, and an attitude that fails to generate interest in and commitment to the care of old people. Unfortunately, this lack of interest often includes disrespect and callousness.
Lack of expertise
The reality is that nursing will increasingly be about the care of older people. I know first-hand that few students enter nursing with the goal of practising gerontological nursing. That's okay. They want paediatrics, or international work (Doctors Without Borders being the current favourite destination), or emergency departments (not appreciating the number of old people who come through EDs), critical care or a cornucopia of other specialties and practice areas. Consequently, schools of nursing must assume primary responsibility for introducing new nurses to the phenomenon of aging and getting them interested in and excited about the care of older people as a fundamental component of nursing – one in which they need to develop a sound knowledge base and set of skills prior to graduation. Most schools are failing in this responsibility.
Having said this, I can hear deans and directors of nursing schools reply, "Et tu, Brute?" Schools are regularly beaten up about what they are not preparing their graduates to do. As a former dean and educator, I am sensitive to the pressure to keep adding content to school curricula in response to various constituencies. But I am adding my voice here because the need is so pervasive and the trend, in terms of demographics, is pointing in only one direction: the number of older people in the population is increasing, and so will the number of older patients in our healthcare system. Failure to prepare students to be competent in the care of older people, including the implications of cognitive impairment imposed on other health problems, is unacceptable. It saddles the healthcare system with nursing staff insufficiently prepared for the demands that will be placed on them.
Many in our current nursing workforce received no preparation in aging and gerontological nursing content as students, and have either not had opportunities to fill this gap or have not taken advantage of opportunities to develop competence. Professional nursing organizations sponsor conferences and workshops where knowledge can be acquired; courses on gerontological nursing are available through many colleges and universities; and the Internet is brimming with information in highly digestible forms. But nurses must recognize the need for this knowledge, or they will not take advantage of the sources that are available.
The concept of "elder-friendly hospitals" is well developed, and its tenets should be standard operating practice for all adult acute care institutions (Parke and Stevenson 1999). Nursing leaders at the unit and institutional levels have a role to play in identifying gaps in the competence of individual nurses and in the nursing workforce under their jurisdiction, as well as organizing for nurses to develop the expertise required. Heads of nursing education programs have similar responsibility: ensuring that faculty members are sufficiently knowledgeable about the care of older people to be able to teach in this field and provide competent clinical supervision of students, and are enthusiastic about caring for older people and the challenges they present. Furthermore, academic leaders must ensure that their curriculum includes a sound preparation in aging and gerontological nursing.
Attitude is quite a different matter. I simply don't understand how nurses can be indifferent in the face of vulnerable old people, how they cannot see how frightened cognitively impaired people are and why they do not identify with the families who are also scared and fear leaving their loved ones with strangers. Nurses should be the leaders in the care of older people. It is such an opportunity for us to demonstrate what we are capable of. High-quality care requires so much of what is fundamental to nursing: providing comfort and reassurance; managing a complex and often confusing interaction of health problems; keeping patients safe; listening and explaining what is happening in language that patients can understand; maintaining function to the extent possible; gentle touching that says "I am here for you"; and much more. Families should be reassured that nurses are caring for their parent, spouse or grandparent, not frightened to leave them with us.
I want to be proud of the care that nurses – that is, all nurses – provide to older people, not be afraid to ask for care. Let's rise to the challenge and show the compassionate, skilled nursing care that we are capable of providing to all our older patients. The effort will be rewarding for all of us.
Parke, B. and L. Stevenson. 1999. "Creating an Elder-Friendly Hospital: One Organization's Experience." Healthcare Management Forum 12(3): 45–48.
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