United States in Search of Nurses with Geriatrics Training

    • February 27, 2012

When it comes to the makeup of the U.S. population, 2012 is the dawn of a new world order.

Last year, the leading edge of the Baby Boom generation turned 65, reaching a milestone that has traditionally marked the onset of older age. Older Americans have a lot to celebrate on their birthdays these days; they are living longer and leading more productive lives than ever before.

But there is a dark side to protracted Golden Years, too. Many older Americans are living sicker, with multiple chronic conditions, but there aren’t enough nurses or other health care providers in the pipeline to meet their increasing, and increasingly complex, needs, experts say.

The problem looms larger with each passing day. Every day until 2030, some 10,000 Americans will turn 65, according to the Pew Research Center. That year, the percentage of Americans over the age of 65 will jump to nearly 20—up from 13 percent today.

Projections like these have nursing workforce experts sounding the alarm.

“There are not enough health providers, nurses included, who either specialize in geriatric care or who possess the necessary competency of geriatrics knowledge in their practice,” says Jennie Chin Hansen, RN, MS, FAAN, CEO of the American Geriatrics Society and the past president of both AARP and the American Society on Aging. That, she says, suggests that many older Americans will not likely get the most knowledgeable care they need when they most desperately need it.

Claudia Beverly, PhD, RN, FAAN, a professor of nursing and director of the Hartford Center of Geriatric Nursing Excellence at the University of Arkansas for Medical Sciences, director of the Arkansas Aging Initiative, and an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2008-2010), agrees. “We do not have anywhere close to the number of nurses we need who are prepared in geriatrics, whether in the field of primary care, acute care, nursing home care, or in-home care,” she says.

As with physicians, many of the nation’s nurses lack expertise in elder care. Fewer than 1 percent of registered nurses (RNs) and fewer than 3 percent of advanced practice registered nurses (APRNs) are certified in geriatrics, according to the American Geriatric Society.

And many nurses lack even basic training in the care of older adults and geriatrics. Only one-third of the nation’s baccalaureate nursing programs required a course focused on geriatrics in 2005, according to the Hartford Institute for Geriatric Nursing. The problem is compounded by a looming shortage of nurses needed to provide care for all people, regardless of age, which will further tax the health care system.

Older patients benefit from care by geriatrics-trained nurses, according to a 2002 article in Health Affairs by Christine Tassone Kovner, RN, PhD, FAAN, a professor of nursing at New York University and co-director of the RN Work Project, a national longitudinal study supported by RWJF that tracks career changes among new nurses. In the article, she cited a study that found that older patients cared for by nurses trained in geriatrics and in complex caregiving are less likely to be physically restrained, have fewer readmissions to the hospital, and are less likely to be transferred inappropriately from nursing facilities to the hospital.

“It’s quite ironic that nursing programs have much more content on pediatrics or obstetrics—clearly needed in the curricula—but so little on complex care and geriatrics, given changing demographics and the fact that the nation spends 75 percent of its health care dollars on chronic disease,” Chin Hansen says. “Providers assume that they are prepared to work with older adults. What they do not realize is that people’s conditions change as they age.”

Train Student Nurses in Geriatrics

One of the key ways to ensure that nurses are able to provide optimal care for the elderly is to include geriatric content in nursing school curricula, Beverly says. “We have to have a concerted effort to mandate that all schools have either a stand-alone course in geriatric nursing and a clinical component, or that they integrate geriatric nursing throughout the curriculum and that we have faculty prepared in geriatric nursing.”

Two major nonprofit organizations—the John A. Hartford Foundation, a philanthropy dedicated to improving care for older Americans, and the American Association of Colleges of Nursing (AACN), a nonprofit organization dedicated to advancing nurse education—have teamed up to help turn that vision into a reality.

Since 2001, AACN and stakeholder organizations have worked collaboratively to develop and promote consensus-based competencies for graduates of baccalaureate, master’s and doctoral nursing programs in an effort to enhance the quality of care available to older adults, according to AACN spokesperson Robert Rosseter. In addition to promoting careers in geriatric nursing and recognizing model educational programs through prestigious awards, AACN has focused recently on nurse faculty development as a mechanism for enhancing geriatric nursing care.

Meanwhile, the Hearst Foundations have agreed to give the National League for Nursing up to $1.2 million over three years to help integrate geriatric content into nursing school curricula.

The efforts comport with a 2008 report by the Institute of Medicine (IOM) that calls for enhanced competency of all individuals in the delivery of geriatric care. A more recent IOM report—The Future of Nursing: Leading Change, Advancing Healthechoes that call. The amount of geriatrics-related content in nursing school curricula has increased, the report states, but is still “uneven” across schools and is “hampered by lack of faculty expertise” in the subject. That needs to change, the report says.

The Future of Nursing report also makes other recommendations designed to help ensure that older Americans will have access to the kind of skilled nursing care and competency they will need in the future, says Chin Hansen, a member of the RWJF-supported study committee that drafted the report. She points to the report’s call for greater interdisciplinary collaboration among health care providers and laws that would support nurses’ ability to practice to the full extent of their training and capabilities, which would help curb looming nurse shortages.

“Geriatrics calls for a much more interdisciplinary way of providing care,” Chin Hansen says. “When somebody has eight or nine health problems, they need providers from different sectors of the health care workforce. It’s a very different way of providing care than is traditionally practiced.”

That model is already in place in some areas. The Program of All-Inclusive Care for the Elderly (PACE) provides Medicare and Medicaid beneficiaries with comprehensive long-term care services from an interdisciplinary team of health professionals. The Acute Care for Elders (ACE) model of care employs interdisciplinary teams in hospital settings. The NICHE program, which stands for Nurses Improving Care for Healthsystem Elders, is in place in nearly 300 hospitals.

And there’s Beverly’s Arkansas Aging Initiative, which provides care for the elderly via teams of geriatricians, APRNs, and social workers that practice across settings. The initiative also educates health professionals and students, older adults and families in care for the elderly.

“Our program has improved health and reduced costs,” Beverly says. “It should be a model for the nation, and it is becoming just that.”

State and federal governments are also getting in on the act. Some states mandate specific geriatric coursework in nursing curricula, according to Kovner. At the federal level, the 2010 health reform law contains provisions that provide funds for a large-scale program to produce more nurses to care for Medicare beneficiaries; strengthen nurse education programs to emphasize training more nurses and more nurse faculty; and promote nurse-managed health centers and nurse-led health care delivery system reforms.

“The Affordable Care Act (ACA) appropriately recognized the need to increase the number of highly-skilled nurses available to care for an aging population and created a number of important tools to better ensure that all Americans can have access to quality health care when and where they need it,” says Winifred Quinn, MA, PhD, director of legislation and campaign operations at the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation. “And through its funding for the new Centers for Medicare & Medicaid Services Innovation Center and funding for nurse-managed clinics, the ACA also provides important opportunities to promote and highlight nursing leadership.”

Despite progress, RWJF Executive Nurse Fellows program alumna (2007-2009) Keela Herr, PhD, RN, AGSF, FAAN, co-director of the Hartford Center of Geriatric Nursing Excellence at the University of Iowa’s College of Nursing and the newly named associate dean for faculty at the College of Nursing at the University of Iowa, still sees major challenges ahead. “But we are taking positive steps toward making sure we have a health care system prepared to care for the aging population by increasing the capacity for caring for older persons by all nurses and health care providers. I think the problem is solvable.”