key: cord-0032041-355yszm2
authors: Resnick, Barbara; Young, Heather M.; Fick, Donna M.; Kagan, Sarah H.
title: Making care for older people the choice of nurses today, tomorrow, and forever
date: 2022-05-21
journal: Geriatr Nurs
DOI: 10.1016/j.gerinurse.2022.04.014
sha: 2431ef9bae6eb6b2cd85ad0ce6a6875adf666b6a
doc_id: 32041
cord_uid: 355yszm2

nan

Making care for older people the choice of nurses today, tomorrow, and forever

The current nursing shortage, whether it is a true shortage of registered nurses or a shortfall in distribution of our available workforce, is inescapable. We read about it, we hear about it, and we live it. The effects of the shortage are most often described in terms of hospitals, focused on those facilities in urban and suburban communities. That focus neglects the place where nurse staffing is always under threat and is now severely compromised: nursing homes. Currently, approximately 50% of nursing homes across the nation report shortages post impact of COVID-19. 1 Nursing homes in rural areas are experiencing even greater duress with the current shortage. 2 While hospitals, clinics, and all clinical agencies are contending with significant shortfalls in their nurse workforce, nursing homes fell even farther behind in meeting staffing needs during the COVID-19 pandemic.

Several factors contributed to nurse shortages prior to COVID-19. Factors specific to each generation's workforce often contributed to this and earlier shortages. Nurses of the Baby Boom generation retiring in this and the coming decade. 3 Their retirement, coupled with the escalating demand for nurses, is not matched by the numbers of people graduating from nursing schools. Additionally, new graduate nurses may move quickly and easily into advanced practice education. Nurses who do so are potentially mitigating the shortage of primary health care providers. Nevertheless, they are simultaneously contributing to the wider nursing shortage. Lastly, workplace concerns like low staffing levels, low morale, and subsequent burnout are pushing nurses out of healthcare entirely.

Issues that keep nurses in nursing homes and what drives them out are unsurprising and much like those that affect nurses in other settings. Not-for-profit nursing homes, those with less turnover in administration, and those that have better staff engagement fare better. Higher regional unemployment and a larger proportion of people living with dementia are among the more unusual factors that help retain nurses. Sadly, but not surprisingly, lower salaries, lack of support for personal health, and bullying and incivility all contribute to nurses leaving nursing homes. 4, 5 Some factors influencing the nursing shortage in nursing homes are specific to that setting. Long-term care is beset by a long history of punitive organizational and regulatory cultures affecting nurses and residents alike. Other factors driving the shortage in this setting are, however, common to all nurses À including underpayment and limited support for personal mental and physical wellbeing. Organizational and cultural forces contributing to the nurse shortage in nursing homes, whether specific to longterm care or widespread throughout our healthcare system, should have been redressed long ago but persist unmitigated.

Enter the pandemic. Nurses are now deemed 'heroes' in social and news media. While such accolades might reinforce nurses' commitment to patient care, they do nothing to address persistent problems that continue to erode nurses' work environments, job satisfaction, and well-being. More than ever, nurses are burnt out as they try to care for increasingly complex patients with limited resources. The mismatch between 'hero' and daily workload is frequently intolerable. Critically, nurses working in nursing homes were further harmed by the public adulation of nurses. The acclaim for nurse 'heroes' frequently zeroes in on those in acute care settings, extending longstanding neglect of those nurses working in long-term care settings. In those settings, resources are limited and have been so for decades. Moreover, complexity characterizes all residents these nurses' care. They are doing far more with far less. As the pandemic drags on, new social factors are emerging as influences in the nursing shortage. The rise of travel and agency opportunities is further widening the salary gap long felt by nursing home staff. Stressors arising from personal demands in childcare, eldercare, and personal health concerns are escalating in salience as nurses consider whether to leave the profession. More than ever, nurses employed in nursing homes are asking 'why should I stay?' and are unlikely to encourage students and colleagues to join them in long-term care.

Alleviating this or any nursing shortage requires change at many levels. System-wide changes must go beyond simply helping staff to feel supported for a shift, a day, or a week. No evidence suggests any long-term effects of token gestures like meals during a shift or gifts of swag. Policy changes must include robust strategies to retain the current nursing workforce. Equity in salary and benefits are paramount. Policy guaranteeing funding and supply chains are necessary to ensure adequate resources for safe nursing practice in all settings, especially nursing homes. Lastly, nursing homes specifically need policy and practice changes to optimize scope of practice and provide around-the-clock professional nurse leadership.

Scope of practice considerations for all members of the nursing team currently limits entry into and retention in professional nursing. Registered nurses (RNs) are frequently prevented from practicing to the full scope of their licensure, hindered by requirements to communicate with providers about management of common clinical finding in the absence of protocols and procedures that support them providing care at the top of their scope. For instance, addressing gaps in care with nursing protocols that facilitate treatment for common problems such as constipation, chronic wounds, and chronic pain amplifies autonomy, enabling RNs to provide innovative care without consulting a provider. Critically, such protocols save precious time for residents and allows RNs to lead in care rather than relying on a provider who likely holds less expertise than they in treating those problems. Similarly, limited scope of practice for certified nursing assistants (CNAs) À nursing team members who are the veritable 

Geriatric Nursing 000 (2022) 1À2

Geriatric Nursing journal homepage: www.gnjournal.com backbone of care in any nursing home À too often fails to match resident need or CNA capacity. For example, training CNAs and altering certification to enable them to give medications addresses unmet clinical needs and maximizes their capacity to contribute to care. Initiatives focused on improving the extent to which RNs and CNAs can provide high quality, holistic care for residents in nursing homes is essential to both the residents' health and to resolving issues that underly the nursing shortage.

Parallel concerns exist in scope for advanced practice nurses (APNs). Policies that ensure APNs can practice to the full scope of their licenses are necessary to ensure residents receive optimal care. Such policies are likely to stem the shortage of APNs in nursing homes by optimizing APN's contributions to access and quality of care for older adults. Expanding efforts to overcome limitations of state-specific licensure offers additional advantages for advancing and ensuring appropriate scope of practice. The Nursing Licensure Compact (NLC), originally approved in 2000, is an agreement between states that allows nurses to have one license but the ability to practice in other states that are part of the agreement. In 2020 a similar process was adopted for Advanced Practice Nurses 2020 referred to as the APRN Compact {National State Boards of Nursing, 2021 #13}. The APRN Compact allows an advanced practice registered nurse to hold one multistate license with a privilege to practice in other compact states. All state boards of nursing must take advantage of both compacts in parallel with efforts to promote APN scope of practice, making practice in any setting À including nursing homes À more attractive and fulfilling.

Addressing the nursing shortage specific to nursing homes must couch advances in policies, procedures, and practices in robust culture change. Reasons to specialize in geriatrics and work with older adults in nursing homes and other settings are clouded by widely accepted ageism, discrimination that affects older adults and the nurses who might choose to care for them. Over the past decades, nurse leaders have designed different programs to draw people into nursing and nurses into geriatrics. The Teaching Nursing Home Model is back in the form of in the Pennsylvania Teaching Nursing Home Pilot (https://www.jhf.org/whatwedo/whatwedo-2/projectsand-programs). Other local efforts include schools of nursing offering robust clinical rotations in nursing homes and programs providing opportunities to students to work in long-term care facilities. Conversely, some long-term care companies offer scholarships that attract students with financial support, training in their nursing homes, and employment or residencies after graduation. All such programs offer some benefits and are likely to achieve success, in concert with other measures, when designed with consideration for local factors relevant to nursing and long-term care.

Dismantling the ageism that persists in nursing and our wider society and resolving issues underlying the nursing shortage in nursing homes requires widespread culture change, undoing mistaken impressions about working in a nursing home and building positive and realistic understandings of what it is to be old today. Ageism intersects with and promotes other forms of discrimination, including racism and gender discrimination along with healthism and ableism. Dismantling all forms of discrimination is critically relevant in nursing homes, with their highly diverse direct care workforce. Creating inclusive working and living environments must be a high priority for all to thrive and to build diverse leadership capacity in long-term care to better serve our increasingly diverse communities.

The many advantages of working in long-term care À from job security to learning from those older adults in our care À are constantly clouded by ill-conceived ageist myths. Consider two myths frequently held up as reasons to avoid working in nursing homes. Myth 1: nursing home practice is boring and repetitive. Truth? The level of complexity and rarity seen in care for nursing home residents is unmatched. Rare conditions are often commonplace. Multi-morbidity is ubiquitous. Technology is limited. Nursing home nurses must rely on astute observations, an orientation to learning constantly, and strong teamwork to ensure optimal care. Myth 2: caring for older people is sad and uninteresting. Truth? Caring for people in their 80's, 90's, and beyond is uplifting, educational, and fun. Trust on this last point À we have an astounding 166 years of geriatric experience among us! Older adults teach us all about resilience and how to bounce back, survive, and thrive even in the worst of times. They remind us that dance parties, walking with someone to dinner, and enjoying a movie or a hobby with friends are ageless joys. You can do all those things in a nursing home À and much more, finding just as much enjoyment in them inside a nursing home as outside.

Today's nursing shortage is not new news to any of us, especially not to those of us who work in geriatrics and long-term care. We all have an investment in resolving the nursing shortage and making care for older people the choice of nurses for today, tomorrow, and forever. With the universal hope of growing old ourselves, we must reimagine nursing and nursing homes for our aging society. Our own healthcare depends on it. We know that nurses everywhere and especially our colleagues in long-term care are truly heroes, but no hero can work against adversity forever. We must all act now to effect necessary change locally and nationally. Our future is in our hands.

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