Dr. Houde is Professor and Director of MS, DNP, and Graduate Certificate Programs, Department of Nursing, and Dr. Melillo is Professor and Chair, Department of Nursing, and Coordinator, Graduate Gerontological Nursing Practitioner Specialty, University of Massachusetts Lowell, Lowell, Massachusetts.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Susan Crocker Houde, PhD, ANP-BC, Professor and Director of MS, DNP, and Graduate Certificate Programs, Department of Nursing, University of Massachusetts Lowell, 3 Solomont Way, Lowell, MA 01854; e-mail: firstname.lastname@example.org.
The population age 65 and older is expected to reach more than 70 million by the year 2030. It is estimated that almost 20% of the United States population will be in this age range by that time (Institute of Medicine [IOM], 2008). Because of a major shift to an aging population and because older Americans typically use more health services, there is concern about workforce needs to care for older adults in the future.
The future health care needs of older adults are largely unknown. It is expected that older adults will have greater ethnic and racial diversity, as well as differences in education and socioeconomic status. It is not clear whether there will be increased morbidity with longer life or whether good health promotion practices will result in a healthier, more active older adult cohort.
However, it is clear there will be a need for a larger workforce that is well prepared to provide care to an older adult population. Both those who provide formal and informal care to older adults are likely to be inadequately prepared in geriatrics. It is expected that the United States will require a 35% increase in formal health care providers by 2030 (IOM, 2008). Complicating the problem of an aging population and a workforce that lacks adequate preparation in geriatrics is the problem of an aging nursing workforce, with large numbers of RNs expected to retire in the coming decades.
A number of changes in the U.S. economy have helped stabilize the present nursing workforce. Buerhaus (2008) identified that more retired nurses are returning to the work-force, part-time nurses are changing to full-time work status, nurses are retiring later, and nurses are working extra shifts. Many of the changes in work status have been spurred by the need for nurses to work more because of spousal layoffs. There is also a trend toward fewer patients being treated in hospitals, which has decreased the need for hospital-based nurses. The stabilization of the nursing workforce is expected to be temporary, with a projected shortage of approximately 285,000 full-time equivalent RNs expected by 2020. This shortage is expected to increase to 500,000 full-time equivalent nurses by 2025 (Buerhaus, Staiger, & Auerbach, 2009).
Shortages of other health care providers who care for frail older adults, including nutritionists, geriatricians, social workers, and pharmacists, are also expected (Resnick, 2007). A response to this shortage of providers with skills in geriatrics has been to introduce increased geriatrics coursework into nursing programs and programs in other disciplines. This effort has been spearheaded by the John A. Hartford Foundation. There has been a call to enhance the “geriatric competence of the entire nursing workforce” (IOM, 2008, p. 6), as well as to increase the number of specialists and to develop innovative models of care for older adults.
Resnick (2007) acknowledged there is a shortage of providers skilled to care for older adults. She advocates the use of interdisciplinary team care that includes joint contributions of team members and blurs boundaries between disciplines. The goals of each discipline are similar, and the strengths of geriatricians, geriatric/gerontological nurse practitioners, geriatric social workers, senior care pharmacists, and physical therapists—when working as an interdisciplinary team—can bring a broader range of high-level skill to the care of older adults.
In particular, long-term care settings have problems with staffing that can affect the quality of care provided to residents. Some of the issues that contribute to staffing problems include high staff turnover rates, increasing levels of care intensity, and low levels of job satisfaction (Cherry, Ashcraft, & Owen, 2007). In a qualitative study, Cherry et al. (2007) found that stressors in long-term care settings were combative, uncooperative residents; residents abusing staff; and frequent deaths. Inadequate staffing and excessive paperwork were identified as problems in nursing homes. Suggestions to decrease turnover in nursing homes included decreasing the amount of paperwork, improving staffing, and addressing stress related to care delivery, especially in the management of behaviors of residents with dementia.
Reducing staff turnover rates can result in cost savings to nursing homes. Because of an increase in new job positions, difficulty in filling open positions, and high turnover rates (especially among nurse aides), evidence shows that actions must be taken to stabilize the workforce in nursing homes to increase the quality of care and promote job satisfaction (Collier & Harrington, 2008).
In the IOM (2008) report Retooling for an Aging America: Building the Health Care Work-force, the Committee on the Future Health Care Workforce for Older Americans proposed that actions need to be taken immediately to increase the numbers in the health care workforce and to prepare the workforce to care for the older adult population in the United States. The Committee promotes the education of both formal and informal care providers in the care of older adults by using the following approaches (p. 2):
- Enhance the competence of all individuals in the delivery of geriatric care
- Increase the recruitment and retention of geriatric specialists and caregivers
- Redesign models of care and broaden provider and patient roles to achieve greater flexibility.
Enhancing the Competence of the Geriatric Workforce
The IOM (2008) Committee called for improved education and curriculum in geriatrics for health care workers but acknowledged challenges related to lack of faculty, few training opportunities, and lack of consistent curricula. Education to address diverse health care needs should prepare professionals to provide care in all settings, including hospitals, nursing homes, assisted living facilities, and home settings. The Committee also recommended inclusion of geriatric content on licensure, certification, and recertification examinations, so all health care professionals demonstrate competence in the care of older adults (IOM, 2008).
Recommendations were also made in regard to direct care workers and informal caregivers (IOM, 2008). It was the consensus of the Committee that the current federal minimum of 75 hours of training for nurse aides was inadequate, and they recommended implementation of a federal minimum of 120 hours for nurse aides and home health aides. Minimum training requirements by states for personal care assistants were also supported (IOM, 2008).
Due to reports that informal caregivers feel inadequately prepared to care for family members in the home, the Committee proposed that training programs be available in the community for informal care-givers and that funding be provided by private, public, and community organizations.
Improving Recruitment and Retention
Responding to the small numbers of professionals who wish to pursue advanced education in geriatrics, the Committee recommended that financial incentives be provided by public and private payers to encourage professionals to pursue a specialty in geriatrics (IOM, 2008). Reexamining reimbursement rates to specialists in geriatrics who provide primary care to older adults is needed, so compensation for extra time to address multiple problems common to the older adult population is considered (IOM, 2008). The Committee proposed the development of a National Geriatric Service Corps, modeled after the National Health Service Corps, which would provide financial incentives, scholarships, and loan forgiveness programs for those who pursue the specialty of geriatrics. Improvements in job environments and increasing financial compensation for direct care work may facilitate the recruitment and retention of staff. The Committee also suggested increasing pay and fringe benefits from state Medicaid programs (IOM, 2008).
Redesigning Models of Care
After reviewing models of care for older adults, the Committee determined that because of the diverse care needs of older adults, a variety of different models of care will be required to meet those needs. Concern was expressed because many of the services required in the models are not reimbursed by Medicare, so new reimbursement methods are needed to promote efficient and effective models of care (IOM, 2008). Consideration should be given to improved reimbursement for mental health services, as well as reimbursement of interdisciplinary teams. The Committee also advocates for Congress and foundations to “significantly increase support for research and demonstration programs that:
- promote the development of new models of care for older adults in areas where few models are currently being tested, such as prevention, long-term care, and palliative care; and
- promote the effective use of the workforce to care for older adults” (IOM, 2008, p. 13).
Training workers with improved skills in delegation, supervision, and technical services was also deemed important. The Committee supports expanded use of technology to improve the ability to coordinate care and increase care efficiency and safety. The work of the Committee provides an important “vision for how the workforce can best be developed and organized to improve its capacity to deliver the care that a new generation of older adults will soon be needing” (IOM, 2008, p. 14).
Several important policy initiatives have been proposed or are under consideration to address the shortage of gerontological nurses and other health care workers. These include initiatives funded by private foundations and major professional nursing associations (e.g., the John A. Hartford Foundation, the American Academy of Nursing, the American Association of Colleges of Nursing), as well as bills introduced in Congress in support of the IOM (2008) report. This section includes a brief description of some of the current initiatives. Robert Binstock, noted policy analyst and political scientist in aging, has suggested a framework for analyzing policy that includes targeting effectiveness (reaching the group intended), administrative ease (whether it can be implemented), and political feasibility (bipartisan support). Consideration should also be given to the cost to the system; impact on quality of care; cost to individuals, families, groups, communities, and society; and resources and expertise required.
As reported on the American Geriatrics Society (2009) website, Senators Barbara Boxer (D-CA) and Susan Collins (R-ME) have introduced the Caring for An Aging America Act of 2009 (S. 750), legislation aimed to address the growing nationwide shortage of health care professionals and direct care workers needed to meet the needs of older adults. According to the Washington Watch (n.d.) website, the latest major action on the bill, dated March 31, 2009, was that it was referred to the Senate committee, read twice, and referred to the Committee on Health, Education, Labor, and Pensions.
The Caring for An Aging America Act of 2009 would amend the Public Health Service Act to attract and retain trained health care professionals and direct care workers dedicated to providing quality care to the growing population of older Americans. It would allocate $130 million over 5 years to fund educational loan forgiveness and training and career advancement opportunities for health care professionals and direct care workers who make a commitment to caring for older adults.
Among other things, S. 750 would establish a Geriatric and Gerontology Loan Repayment Program for physicians, physician assistants, pharmacists, advanced practice nurses, psychologists, and social workers who complete training in geriatrics or gerontology and agree to provide care for older adults, full time, for at least 2 years. The Act would also expand eligibility for the Nursing Education Loan Repayment Program to include RNs who complete specialty training and provide services in long-term care settings.
This bill aims to expand education and training opportunities in geriatrics and long-term care for both licensed and other direct care health professionals and for family caregivers. It would support a National Resource Center on Students, Volunteers and Seniors, thereby engaging a new generation of nurses, social workers, therapists, nutritionists, pharmacists, and other professionals in the long-term care field.
The Caring for An Aging America Act of 2009, if approved, does address targeting effectiveness by identifying the gerontological nursing shortage area, providing advanced training and educational opportunities for practicing nurses (“retooling”) and those pursuing advanced degrees in a serious health care shortage area. Administrative ease with this amendment to the already existing Public Health Service Act is possible, while targeting effectiveness for the areas of geriatric nursing, geropsychiatric care, long-term care, and chronic care management. Political feasibility and bipartisan support are yet to be determined, but the economic climate and need to provide economic stimulus with enhanced job opportunities in an area of need may positively affect support of the bill.
Another bill, H.R. 468, was first introduced in the 111th Congress on January 13, 2009, and proposed to expand, train, and support all sectors of the health care workforce to care for the growing population of older adults in the United States. It has been referred to the House Committee on Energy and Commerce, in addition to the Committee on Education and Labor. Two sections of this bill are particularly important:
- Sec. 104. Geriatric Career Incentive Awards. This would amend Section 753 of the Public Health Service Act (42 U.S.C. 294) by adding Geriatric Career Incentive Awards that would award grants or contracts to individuals to foster greater interest among health professionals in entering the field of geriatrics, long-term care, and chronic care management. Advanced practice nurses or those with advanced degrees in geriatrics, long-term care, geropsychology, or chronic care management from an accredited health professions school approved by the Secretary would be eligible. Recipients must agree to teach or practice in the field of geriatrics, long-term care, or chronic care management for a minimum of 5 years. An appropriation of $10 million for the period of fiscal years 2011 through 2013 has been requested.
- Sec. 121. Comprehensive Geriatric Education Nursing Grant Program. This program would establish federal traineeships to individuals preparing for advanced degrees in geriatric nursing, long-term care, or geropsychiatric nursing. It would provide assistance to support additional training for nurses who care for older adults and individuals with disabilities, and for the development and dissemination of curricula related to geriatric nursing care, the training of nursing faculty in geriatrics, and the provision of continuing education for nurses practicing in geriatrics. Under this section, $25 million for each of the fiscal years 2011 through 2013 is requested.
On January 14, 2009, a companion bill, S. 245, was introduced by Senator Herb Kohl (D-WI). This bill would expand, train, and support all sectors of the health care workforce to care for the growing population of older individuals in the United States. It was referred to the Committee on Health, Education, Labor, and Pensions (S. 245—The Retooling the Health Care Workforce for an Aging America Act, 2009).
The American Recovery and Reinvestment Act of 2009 has made funds available to provide training, education, and job placement assistance for workers in high-growth areas, one of which is long-term care. The Act supports projects that encourage progression along the career pathway for nurses, as well as credentialing and certification for other health care workers (U.S. Department of Labor, Employment and Training Administration, 2009). Given the health care workforce concerns expressed by the IOM (2008), training and educational support for long-term care careers, including nurses in long-term care settings, are an important funding focus (U.S. Department of Labor, Employment and Training Administration, 2009).
Another important initiative through the American Academy of Nursing’s (n.d.) Building Academic Geriatric Nursing Capacity program is a scholarship and fellowship program for nurses who wish to pursue doctoral study and research in geriatric nursing. The Predoctoral Scholarship supports doctoral work in geriatric nursing, and the Claire M. Fagin Fellowship provides funding for doctorally prepared nurses pursuing research in geriatric nursing. Both programs are supported by the John A. Hartford Foundation and the Atlantic Philanthropies (American Academy of Nursing, n.d.).
Nationally, professional nursing associations and specialty organizations have also been very active in identifying potential solutions to the gerontological nursing and health care workforce shortage. Two John A. Hartford Foundation-funded initiatives are currently underway. One initiative by the Hartford Institute for Geriatric Nursing, in partnership with the American Association of Colleges of Nursing, supports the national project, “Advanced Practice Registered Nursing Initiative Transitioning to Adult-Gerontology APRN Education: Ensuring the APRN Workforce is Prepared to Care for Older Adults” (Hartford Institute for Geriatric Nursing, 2008). In February 2009, a nurse practitioner expert panel was convened to develop nationally recognized, consensus-based competencies for adult-gerontology nurse practitioners and clinical specialists. Ultimately, the identification of consensus-based competencies for the integration of gerontological nursing into advanced practice nursing curricula in all specialties and role preparations will be essential in preparing a workforce to care for an aging America.
Another national initiative is the Geropsychiatric Nursing Collaborative (GPNC) (American Academy of Nursing, 2008). A description follows:
In January 2008 the John A. Hartford Foundation awarded the American Academy of Nursing and the Universities of Arkansas, Iowa, and Pennsylvania a four year collaborative project to enhance the cognitive and mental health of older Americans.
The Geropsychiatric Nursing Collaborative (GPNC) is designed to help improve the education of nurses for the care of elders suffering depression, dementia and other mental health disorders. The collaborative effort will enhance extant competencies for all levels of nursing education, focusing them on older adults with mental health/illness concerns. The competency statements together with curriculum materials developed for basic, graduate, post-graduate, and continuing education nursing programs will be shared via this website beginning mid to late 2009.
The charge of the GPNC is to develop and come to consensus around a general definition of geropsychiatric nursing and develop revised or new competency statements for each level of nursing practice (i.e., pre-professional baccalaureate/entry-level nursing; advanced practice nurse specialties including family, adult, women’s health, and acute care; advanced practice specialties in gerontological and psychiatric mental health). Dissemination of the recommendations for enhancement to curricular and practice models is forthcoming.
In 2006, the Robert Wood Johnson Foundation issued a report, Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace, which speaks specifically to the need to address the aging nursing workforce (Hatcher et al., 2006). Despite many programs being in place in health care settings to recruit and retain qualified nursing professionals, seldom is there a similar strong emphasis on the aging of the nursing workforce itself. What technological advances and role opportunities have the nursing profession implemented that would encourage the sharing of the wisdom, leadership, and clinical expertise of expert nurses to the next generation of nurses? How can work schedules be modified to take into consideration the age-related changes of nurses themselves in being able to continue to contribute to the needs of a health care system that should be valuing their expertise? Has the profession identified what the future nursing competencies will be and how the nursing profession will partner in the academic and practice settings to achieve those competencies? Do these competencies reflect the integration of all members of the nursing profession, including the aging nursing workforce?
In any consideration of work-force policy as it relates to an aging America, the concomitant goals of improved quality, cost effectiveness, and accessibility of health care to an aging population will be paramount. These policy goals for quality care, as well as considerations for the aging nursing workforce, must continue to be addressed. These measures, coupled with the important need to recruit qualified candidates into the field of gerontological nursing and offer all practicing nurses gerontological knowledge and skills, are necessary to ensure best practices are implemented in the variety of health care settings where older adults will be cared for in the future.
- American Academy of Nursing. (2008). Geropsychiatric nursing collaborative. Retrieved from http://www.aannet.org/i4a/pages/index.cfm?pageID=3833
- American Academy of Nursing. (n.d.). Building academic geriatric nursing capacity: Applications. Retrieved from http://geriatricnursing.org/applications/applications.asp
- American Geriatrics Society. (2009). American Geriatrics Society Applauds Sens. Barbara Boxer and Susan Collins’ “Caring for An Aging America Act of 2009.” Retrieved from http://www.americangeriatrics.org/news/pressrelease_033109.shtml
- Buerhaus, P.I. (2008). Current and future state of the US nursing workforce. Journal of the American Medical Association, 300, 2422–2424. doi:10.1001/jama.2008.729 [CrossRef]
- Buerhaus, P.I., Staiger, D.O. & Auerbach, D.I. (2009). The future of the nursing workforce in the United States: Data, trends, and implications. Sudbury, MA: Jones and Bartlett.
- Cherry, B., Ashcraft, A. & Owen, D. (2007). Perceptions of job satisfaction and the regulatory environment among nurse aides and charge nurses in long-term care. Geriatric Nursing, 28, 183–192. doi:10.1016/j.gerinurse.2007.01.015 [CrossRef]
- Collier, E. & Harrington, C. (2008). Staffing characteristics, turnover rates, and quality of resident care in nursing facilities. Research in Gerontological Nursing, 1, 157–170.
- Hartford Institute for Geriatric Nursing. (2008). Hartford Institute programs and projects. Retrieved from http://hartfordign.org/about_us/Hartford_Institute_Programs/
- Hatcher, B.J., Bleich, M.R., Connolly, C., Davis, K., Hewlett, P.O. & Hill, K.S. (2006). Wisdom at work: The importance of the older and experienced nurse in the work-place. Retrieved from the Robert Wood Johnson Foundation website: http://www.rwjf.org/files/publications/other/wisdomatwork.pdf
- H.R. 468, To expand, train, and support all sectors of the health care workforce to care for the growing population of older individuals in the United States. (n.d). Retrieved from the Library of Congress website: http://thomas.loc.gov/cgi-bin/bdquery/D?d111:4:./temp/~bdFIDn::
- Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Retrieved from the National Academies Press website: http://www.nap.edu/catalog.php?record_id=12089
- Resnick, B. (2007). An alternative solution to our shortage of nurses, physicians, pharmacists, and other health care providers. Geriatric Nursing, 28, 207–209. doi:10.1016/j.gerinurse.2007.06.002 [CrossRef]
- S. 245—The Retooling the Health Care Work-force for an Aging America Act. (2009). Retrieved from the Office of Legislative Policy and Analysis website: http://olpa.od.nih.gov/tracking/111/senate_bills/session1/s-245.asp
- S. 750, The Caring for an Aging America Act of 2009. (n.d.). Retrieved from the WashingtonWatch.com website: http://www.washingtonwatch.com/bills/show/111_SN_750.html
- U.S. Department of Labor, Employment and Training Administration. (2009, July22). American Recovery and Reinvestment Act of 2009; Notice of availability of funds and solicitation for grant applications for the health care sector and other high growth and emerging industries. Federal Register, 74(139). Retrieved from http://www.doleta.gov/grants/pdf/SGA-DFA-PY-09-01.pdf