Talk about a momentous birthday—the oldest baby boomers started celebrating their 65th birthdays in 2011, ushering in what appears to be a huge change in health care demands in the United States. As the population ages in unprecedented numbers and is living longer than at any other time in history, the field of gerontological nursing is facing big changes with staffing needs and day-to-day practices.
Experts in gerontological nursing are reporting a greater demand for nurses now and in the future. As the number of patients increases, a sufficient number of nurses will be needed to care for them and to relieve the workload. The solution is complex and depends on the collaborative actions of government agencies, health care providers, colleges and universities, and nurses themselves.
According to a 2005 report by the National Institute on Aging and the U.S. Census Bureau, projections indicate that by 2030 the older population will total 72 million residents, doubling the number from the year 2000. By that time, one in five citizens will be 65 or older. And, according to the report, seniors are living longer lives, but 80% of them have at least one chronic health condition (such as heart disease, diabetes, or respiratory problems) and half of them have at least two. So even as the population enjoys living longer, the health care needs of older adults are more complicated.
"There is a strong assessment that the current workforce today is not prepared to care for the population," says Amy Cotton, M.S.N., G.N.P.-B.C., F.N.P.-B.C., F.N.G.N.A., and president of the National Gerontological Nursing Association. "Another issue of great concern for colleges is when graduates are not prepared to care for the population they have to care for, it creates a lot of job stress and can lead to a lot of turnover."
Typically, health needs become more complex as people live longer lives. There is a pressing need for competencies surrounding normal aging, cultural norms, and the very fine line of effective communication with the patient. And as the age gap between the younger workforce and the increasingly older patient gets wider, awareness of those variations is essential to provide good care.
"Those generational differences can create a schism," says Valerie Kaplan, Ph.D., A.R.N.P., F.N.P.-B.C., F.A.A.N.P. and a senior policy fellow with the American Nurses Association. For instance, older generations grew up following a doctor's orders with no questions asked. Younger generations—who often search for second opinions and cutting-edge treatments—might find that a puzzling way to approach personal health.
In addition to the age differences, census predictions indicate that the population will be composed of more ethnically diverse elders by 2030, with 72% being non-Hispanic white, 11% Hispanic, 10% African American, and 5% Asian. "There is a diversity explosion in growth for various ethnic groups in this country," Cotton says.
As those populations age, there arises a pressing need for more diversity among nurses. Cultural awareness of family expectations, patient lifestyle, and cultural norms often gives the nursing staff an indication of how to proceed with care plans. The more a nurse knows about a patient, the more likely the care plan will be successful from the beginning.
Natalie Nieves, a case manager for VNA Health Care of Hartford in Connecticut, sees firsthand the need for nurses of all backgrounds. "Minorities can be majorities in the inner cities," she says. "Being bilingual is a plus in my field. [Patients] trust you a lot more, and they confide in you a lot more."
When a Spanish-speaking patient can speak with a nurse also fluent in that language, they glean more from the conversation, since the details do not get lost in translation. "There is no barrier," Nieves says. "It is clear, concise, and direct. It is amazing the difference it makes." As valuable as an interpreter is, having a relationship where both parties speak the same language just makes it easier. "When a nurse goes out with an interpreter," says Nieves, "the patient feels like they are talking to two people at once."
The elderly patient benefits are both emotional and physical when they are receiving health care from a bilingual nurse. "There has to be an understanding of how cultural norms impact decisions," says Tara Cortes, Ph.D., R.N., F.A.A.N., Executive Director of The Hartford Institute for Geriatric Nursing and professor at New York University's College of Nursing. For instance, Nieves, who is of Hispanic descent and fluent in Spanish, has noticed this in her own practice when she visits patients who might not relate how a diet full of foods traditional to his or her upbringing might impact something like blood sugar levels.
"We need to encourage minorities to nursing," says Nieves. "We need them out there."
For most nurses working with an older population, good communication is of primary importance. "If you can't, at a basic level, communicate with an older adult, you will miss the boat when caring for that adult," Cotton says. "That communication is a critical piece and a basic piece that is easily missed. We have such a hurry-up system."
Sabina Ellentuck, who is launching a second career as a nurse, says she tries to take a breath and focus on the patients before she approaches them. In a way, quieting her own thoughts helps her slow down, greet her patient, find out how they are doing, and speak with them for a while before moving on to the health care procedures. "You have to be able to connect with them or they will not listen or do what you ask," she says.
That bit of personal interaction also gives a valuable perspective. "It is feeling good and communicating and having fun with them," says Ellentuck. "On top of which there is this big need."
Most nurses, whether or not they work primarily with a geriatric population, will care for elderly patients at some point in their careers; knowing the normal signs of aging is an essential skill. "You have to think of what aging does to vision and hearing," says Cotton. There can be changes in balance, memory, or mobility. Personal interactions and communication also allow nurses to glean an understanding of what is a normal result of aging and what might be a red flag for something more serious.
But nurses feel the time crunch. "There is pressure to do things quick, but it is extremely important to connect with the patient and be a good detective and pick up signs when something is wrong," Ellentuck says. "It is hard to do that when you are rushed. The balance really is the challenge of integrating good health care while doing all these things."
While the need for nurses continues to grow, pay disparity is often a roadblock, says Cotton. When nurses can earn more money in an acute care setting than in a long-term facility setting, they are generally drawn to the higher pay scale. Cotton says payment reform has to occur to attract more nurses to the field. After all, many nursing students graduate shouldering large debts, and paying them off is of primary importance. "It is hard to support yourself with what a geriatric nurse makes today," says Cortes.
Many experts say the foundation for successful gerontology nursing practices begins in school and continues as nurses enter the workforce.
"The first exposures to gerontological nursing practices are critical," says Cotton at the National Gerontological Nursing Association. Students need exposure to healthy, vibrant elders, as well as those who are sick or frail. And age does not always indicate health. Students need to be able to refute the myth that aging goes hand-in-hand with illness. "Changing that perception requires interaction with healthy and well elders," says Cotton.
Valerie Cotter, D.N.P., A.N.P./G.N.P.-B.C., F.A.A.N.P., and advanced senior lecturer and Director of the Adult Health Nurse Practitioner Program at the University of Pennsylvania School of Nursing, says schools are trying to make it interesting for students to come into the field of geriatric nursing. One of the best ways for that to happen is for students to see the passion that so many professionals have for working with an older population. Describing that job satisfaction to students is essential, Cotter says, especially if the students have not had an opportunity to experience in their own lives.
"I was fortunate to have a good relationship with my grandparents," says Cotter. "As a nurse, I gravitated to older adults. I love the life story and the narratives. Older adults have many more experiences, and you look at health within the context of those life experiences." Through education as well as their personal experiences, nurses are able to sharpen their skills to the complex needs of the elderly and recognize red flags quickly. "You have to know the baseline status to recognize change," says Cotter.
In 2002, according to an article in Health Affairs, 58% of baccalaureate nursing programs had no full-time faculty with specializations in geriatrics.1 "We still don't have enough geriatric content built into the undergraduate curriculum," says Cortes. "We need nurse practitioners for geriatric care. We do not have enough physicians to care for this population. Nurses can do a tremendous job of keeping the older population safe and at home and functioning at their highest level."
Even a nurse who works in ICU needs to know if the patient has had a flu shot to provide comprehensive care. A nurse might encounter a healthy and active 90 year old or 67 year old with high blood pressure, complications from diabetes, or other serious health issues. "The reality is we are still providing care for adults across the continuum," says Kaplan. "As they age, their health care needs are not driven by where they end up in the health care facility, but by the health care problems. [Nurses] need to identify the care needs of patients not based on where they work."
While an important foundation of geriatrics is educational, Kaplan says, nurses need a general understanding of what it is to care for someone who has lived through different times. "The brain changes are sometimes more challenging than the physical changes," Kaplan says. They are also more difficult for some family members to come to terms with. The nurse's job, says Kaplan, is to be present for the patient. "If they are in 1945, then you are in 1945," she says. "It is important that nurses as caregivers recognize that and not challenge that."
Nieves says there is so much going on with an elderly patient that nurses are forced to use all their nursing skills on the job. "You use every single thing you have got," she says. "I really truly enjoy my job."
The industry is constantly developing models for consistent, coordinated, and collaborative care for older adults, says Cortes, but it is the nursing staff that carries it out. Nurses care for the whole person, she says. Caring for an elderly population is much more complex than treating only health issues. With elderly patients, you must consider their lifestyle. Are they eating enough? If not, is that because they forget or because they do not have enough access to food or transportation to get food? Do they have a small appetite? Is their medication impacted in any way by their foods? Are they taking their medication exactly as prescribed? How involved is the family, and how will family beliefs and attitudes change the course of the care?
To encourage nurses to specialize in geriatrics, it's important to get nurses into the field and show them how rewarding it can be. "I'd love to see the number of nurses certified in geriatric nursing and practicing as NPs, and caring for elder adults increase," says Cortes. "Nurses will be much more involved in developing those practices. It is very positive."
Ellentuck finds the changes galvanizing. "It is a very exciting time now in how we think of helping older adults—many assumptions no longer exist," she says. "A prime focus now is on function and getting people moving, moving out of those wheelchairs (if possible), doing activities that connect to the person's interest or background. . . . To me, this is very exciting, and I look forward to being involved and doing these new practices that are truly patient-centered care."