Why don't nursing homes hire master's-prepared gerontologicai nurses? The most frequently given answer to this question is that nursing homes hire the minimum staffing required to maintain compliance with regulations. Perhaps it is time to explore a different answer. Perhaps it is ti me to ask if master's-prepared gerontological nurses are educated to meet the needs of nursing homes.
Nursing curricula is biased toward the acute care setting, but nursing homes differ from acute care settings tn many ways. One way in which they differ is in availability of resources. One needs only to look at daily hospital and nursing home rates to find that nursing home care costs about one sixth as much as care in nonintensive units in an acute care setting. Given today's economic climate, it is highly doubtful that future government funding of long-term care will increase. Thus, available fiscal resources translate to fewer staff, less educated staff, and less technology.
Educational programs that teach only the highest quality of care, requiring acute care resources, are bound to be a source of frustration to the new master's graduate. When taught such an ideal, the nurse is often unable to reach it, not for lack of effort, but for lack of resources. The result, however, is frustration and a conscientious person who will need to leave the setting - if not the discipline - to maintain self- integrity.
On the other hand, teaching that quality of care is on a continuum and that the challenge in any setting where resources are limited (ie, the community and the nursing home) is to achieve the highest quality of care possible given the resources available is more realistic and obtainable. Moreover, when the quality of achievable care is less than that desired, then the nurse as an advocate will take action to change the resources in the system through administrative or political action.
Such a viewpoint requires a change in curriculum as well as the educational process. Geronto logica I nursing curriculum should build to match the complexity of working with older clients. Beginning with health promotion, adding chronic illness problems, and following with acute care problems, students learn that health promotion is always appropriate and that older persons experiencing acute problems are managing chronic problems at the same time.
Practicum experiences should reflect the realism of practice in the community with opportunities for health promotion with the well elderly, as well as with those managing chronic illness in the home. Given that nursing home beds now outnumber acute care beds, the nursing home is a necessary experience Jn conjunction with acute care. Through hands-on experience with older clients, students learn that the majority of older people manage a meaningful life despite chronic disease.
In addition to gerontologi cai nursing content, reimbursement, and policy issues, content is necessary if master's-prepared graduates are to understand the economics of service delivery. It is not difficult for master's- or even doctorally-prepared nurses to secure nursing home positions at reasonable salaries if they increase quality of care and reimbursement. Knowledge of political issues in health care will enhance the nurse's effectiveness as a client advocate.
Other important content is family dynamics to better support families in meeting the needs of older family members. Human resource management is also highly recommended. In nursing homes and particularly the community, professional judgments are made by the nurse who then relies on others to carry out much of the bedside care. Few programs currently prepare the new graduate to work through others.
Research is also an important aspect of the educational program. It will assist the nurse in maintaining an updated practice, and knowing the research process will assist the nurse in setting up program evaluation. Data are the effective way to convince administrators and legislators of needed change.
It is important for students to view the older client from the perspective of nursing. A nursing theory class will help students focus on what nursing is and what it is not. This knowledge will help in the prioritization of scarce nursing time. Moreover, students can explore the use of theory when the nurse-client interaction takes place over time in a variety of settings. For the gerontologi cai nurse, this often continues over a period of years, ending with the eventual death of the client. Few nurse theorists, with the exception of Henderson, speak to death as a concept in nursing practice. Teaching nurses to care about themselves as they care for and eventually support the client and family during dying is important for the nurse to continue to connect with and care for older clients.
Gerontological nursing practice is challenging in the nursing home setting. It is time for nursing educators to prepare gerontological nurses.