Care Provision for Older Adults: Who Will Provide?

Lorraine C. Mion, PhD, RN

Abstract

The aging of the baby boomers comes at a time of a growing nursing workforce shortage: registered nurses,
nurse aides, and nursing faculty. Older adults have multiple physical, social, and psychological conditions,
making the assessment, planning, and delivery of health care more complex than that of younger adults.
Not surprisingly, this age group also utilizes the majority of health services in the country. Thus, most
nurses will provide care to older adults in a variety of settings. However, the majority of nurses have little to
no background in geriatric nursing. These multiple forces: aging population with complex needs, nursing
work force shortage, and lack of geriatric knowledge, along with fewer resources, will have a grave impact
on health care in this country in the near future. This article reviews issues related to an aging population,
the projected nursing workforce shortage, and the lack of geriatric nursing education; it concludes with
suggestions for future health care delivery to the geriatric population in the US

Citation: Mion, L. (May 31, 2003). "Care Provision for Older Adults: Who Will Provide?" Online Journal of
Issues in Nursing. Vol. 8 No. 2, Manuscript 3. Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume8
2003/No2May2003/CareProvisionforOlderAdults.aspx

Key words: nursing workforce, geriatric nursing, aging population

Care Provision for Older Adults: Who Will Provide?

....nearly 6,000 Americans will celebrate a 65th birthday each day. Ten years from today, the US will have
nearly 10,000 people a day turning age 65. And still, too few doctors, nurses and other health professionals
receive any formal training in how to provide the best care for older patients (Alliance for Aging Research,
2002, p. 2).

The growing proportion and numbers of older adults in the American population will have a profound impact
on all sectors of society, including health care. Currently accounting for 12.4% of the population, by the year
2030 the older U.S. population will double to about 70 million and account for 20% of the population
(Administration on Aging, 2002). With few exceptions, a nurse’s typical patient is an older adult, age 65 or
older. Older adults account for over 60% of all adult ambulatory visits, 80% of home care visits, 49% of all
hospital days, and comprise 85% of all long-term care residents (Centers for Disease Control and
Prevention, 2002). Although best geriatric nursing practices have been shown to improve care processes
and outcomes of older patients, diffusion of this knowledge into mainstream nursing has been slow.
Compounding the lack of geriatric knowledge, there is a growing shortage of registered nurses (RNs). At a
time of an increasingly aging population with complex care needs and an increasingly complex technological
care environment, the potential lack of skilled RNs is alarming (Kimball & O’Neil, 2002). This article reviews
the intersecting forces of the aging population, the nursing workforce shortage, and the lack of geriatric
education and training, which will have a profound impact on the health care industry unless steps are taken
soon. Recommendations to address these issues are provided.

Aging Population and Impact of Chronic Illnesses

Over the past century, the life expectancy for both men and women has increased dramatically, from 46
years in 1900 to 78 years currently. This increase in longevity has been primarily due to changes in public
 health, the advent of antibiotics, and advances in medical technology (Administration on Aging, 2002). With
longevity, however, comes the increased likelihood for chronic medical conditions (Administration on Aging;
Alliance for Aging Research, 2002; Wolff, Starfield, & Anderson, 2002). A large cross-sectional study of over
1,000,000 older adults revealed that 82% had one or more chronic conditions. Moreover, the prevalence of
chronic conditions increased with age from 74% for those 65 to 69 years, to 88% for those 85 years or older
(Wolff et al.). A significant proportion had multiple conditions: 43% of all older adults had three or more
chronic conditions, and 24% had four or more chronic conditions. Associated with chronic illnesses are
disabilities. After age 50, the likelihood of an individual being disabled by disease doubles every five to
seven years ( Alliance for Aging Research). Of those 65 to 74 years, 26% reported limitations due to chronic
conditions; almost half (45%) of those 75 years and older reported one or more limitations due to chronic
conditions.

Because of these multiple chronic conditions, the older population utilizes a

Among acutely ill older adults, large proportion of the health care services. The mean per capita Medicare
hospitalization itself poses a expenditure during 1999 was $5,015 (Wolff et al., 2002). As chronic
serious threat to the health and conditions increase, so do Medicare expenditures, from $211 per individual
functioning of older adults. with no chronic conditions to $13,973 among individuals with four or more
chronic conditions. Similarly, inpatient hospital utilization rose with the number and types of chronic
conditions. Those with one chronic condition were 7.5 times as likely to incur an inpatient admission
compared to those with no chronic conditions. Patients with four or more chronic conditions were 99 times
as likely to be hospitalized (Wolff et al.).

Nearly two thirds of the Medicare beneficiary population has three or more chronic conditions (Wolff et al.,
2002). The interaction of multiple disease states coupled with the psychosocial needs frequently present in
this population makes the assessment, planning, and delivery of health care more complex than that of
younger cohorts. The care needs of older, acutely ill patients are much more complex and difficult to
manage than those of other age groups. Among acutely ill older adults, hospitalization itself poses a serious
threat to the health and functioning of older adults. For instance, approximately one-third of hospitalized
older adults have a decline in their ability to perform one or more activities of daily living (ADLs) at
discharge, and up to 15% of hospitalized older adults develop an adverse drug reaction (Creditor, 1993;
Riedinger & Robbins, 1998).

There are a number of perils to the structure and process of health care delivery in the hospital setting
(Bowar-Ferres, 2002). The high acuity of patients has turned most tertiary care centers into large intensive
care units. The shortened length of stay mandated by third party payors has compressed the delivery of
care to a frenetic pace. The reduction of hospital beds in the early 1990s and the growing acuity have
created capacity issues of not enough beds, overcrowded emergency departments, and sights of stretchers
lined in hallways. Environmental issues of too much stimuli and lack of space for assistive devices (such as
walkers and bedside commodes) place the older patient at greater risk for delirium and falls. Insufficient
staff is well known with the nursing shortage. Financial constraints from health care revenues have led to
low margins and are unlikely to resolve soon, given the current changing and competing priorities in
Congress. Information gaps within the health care system are a common complaint among patients and
health care providers alike. Inability to access prior records or obtain information from other referring
agencies complicate not only the quality, but also the actual delivery of care. Combining these perils with
the surge in the older population will only further compound the optimal outcomes from acute care.

Older adults also use the majority of home services. Approximately 69% of home care recipients are age 65
years or older. Forty-five percent of direct care by RNs in the community setting is given to those 65 years
and older (Kovner, Mezey, & Harrington, 2002). Nursing home residents are predominantly elderly,
accounting for close to 90% of all nursing home occupants (Kovner et al.). The majority of nursing home
residents require assistance with activities of daily living and have significant cognitive impairments
(Administration on Aging, 2002; Kovner et al.).
Nursing Workforce Shortage

Two factors of the nursing workforce are impacting the delivery of care to older adults, both currently and in
the near future. Specifically, these factors are shortages of RNs, non-licensed nursing personnel, and
nursing faculty, along with an aging nursing workforce. There have been a number of reports on the recent
shortage of RNs (Kimball & O’Neil, 2002). Multiple interacting factors account for this RN shortage, including
increased complexity of patient care; dropping enrollments in schools of nursing; lower compensation as
compared to other career choices; low job satisfaction; and multiple alternative careers for women (Kimball
& O’Neil; Scanlon, 2001; Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000).

Increased complexity of patient care increases the demand for nurses with specialty training, such as critical
care and emergency departments (Scanlon, 2001). Increased technology in all settings has increased the
demand for a higher skill mix of RNs. Moreover, the expansion of care delivery to community, ambulatory,
and long-term care settings has increased both job opportunities and demand for nurses (Scanlon).

Surveys have been conducted annually on enrollment into baccalaureate schools of nursing. Schools of
nursing have experienced an overall decreased enrollment of 21% spanning six consecutive years, from
1995 through 2000 (American Association of Colleges of Nursing [AACN], 2002b). While last year’s
enrollment in baccalaureate programs increased 3.7% over the previous year, it was still lower than
enrollment figures prior to 1995 and insufficient to meet current demands (AACN, 2002b).

Job dissatisfaction may play a critical role in determining the extent of future nurse shortages.

Indeed, job dissatisfaction is a primary reason cited for nurse retention problems for hospitals as well as
nursing homes (Scanlon, 2001). There is a disturbing indication that job
dissatisfaction among nurses is high. Aiken and associates (2001)
Job dissatisfaction may play a
surveyed nurses in five countries and found that over 40% reported job
dissatisfaction. Surveyed nurses consistently reported perceived hospital critical role in determining the
nurse staffing levels that were inadequate to provide safe care, leading extent of future nurse shortages.
to increased pressure to accomplish work, need for overtime, and stress-related illnesses. Another survey
found that half of currently employed nurses were considering leaving the health care field for reasons other
than retirement (Scanlon).

While shortages have occurred in the past, this current shortage is particularly worrisome since 49% of all
RNs are baby boomers (Buerhaus, Staiger, & Auerbach, 2000). Nurses start withdrawing from employment
at 55 years of age (Minnick, 2000). Thus, between 2005 and 2010, the withdrawal of baby boomer RNs will
have a profound impact on U.S. health care (Buerhaus et al.; Minnick; Spratley et al., 2000). The younger
retirement age of nurses as compared to the general workforce is due to a variety of factors, including
financial and family issues, and the heavy physical demands of the profession (Berliner & Ginzberg, 2002).
Besides retirement, the aging of the RN workforce has another important implication for employers. In 2000,
the average age of hospital nurses was 41.8 years, 45.3 years for community nurses, and 49.4 years for
faculty (Spratley et al.). By 2010, more than 40% of RNs will be older than 50 years (Buerhaus et al.). Older
RNs are more likely to suffer back, neck, and foot injuries, and have a reduced capacity to perform physical
tasks as compared to younger RNs (Buerhaus et al.).

The shortage of nurse aides is also at a critical level. There are already reports of 100% turnover rates
among nurse aides in nursing home settings (Scanlon, 2001). With the aging of the population, the demand
for nurse aides is expected to rise dramatically; indeed, nurse aide jobs increased 40% from 1988 to 1998
(Scanlon). The traditional individual who fills the nurse aide role is a woman between the ages of 20 to 54
years; yet nursee aide numbers are expected to increase by only 9% between 2000 and 2030. Somewhat
similar to factors affecting nurse retention, the rapid turnover of nurse aides is due to low wages, difficult
working conditions, and fewer benefits compared to other service entry workers (Scanlon). The workload for
 nurse aides is particularly heavy. Also, nurse aides have the highest rate of workplace injury,13 injuries per
100 employees, as compared to the construction industry with 8 injuries per 100 employees (Scanlon).

Low staffing levels of nurses and nurse aides have already been linked to poorer quality of care and
outcomes. In a cross-sectional study involving 10,184 staff nurses and 232,342 general, orthopedic, and
vascular surgery patients, Aiken, Clarke, Sloane, Sochalski, and Silber (2002) found an association between
increased patient mortality and lower nurse staffing levels. In a large, multi-state sample of hospitals,
Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky (2002) found that a higher proportion of nursing
care provided by RNs and a greater number of hours of care by RNs per day was associated with better care
for hospitalized patients. A higher proportion of hours of care per day by RNs was associated with shorter
length of stay; lower rates of urinary tract infections, pneumonia, gastrointestinal bleeding and shock; and a
lower rate of cardiac arrest among medical patients. Among surgical patients, a higher proportion of care by
RNs was associated with lower rates of urinary tract infections and death from shock or cardiac arrest
(Needleman et al.). Low nurse aide staffing has also been shown to impair the quality of care; 54% of
surveyed facilities do not meet the minimum threshold of 2.0 hours per resident day (Scanlon, 2001).

Compounding the nursing workforce shortage is the growing nursing faculty

Compounding the nursing shortage. Last fall, 39% of the schools of nursing cited faculty shortages as
a reason for not accepting applicants (AACN, 2002a). A number of factors
workforce shortage is the growing
contribute to the faculty shortage. First, few nurses obtain advanced
nursing faculty shortage. degrees. Doctorally prepared nurses, most of whom work in schools of
nursing, comprise only 0.6% of the nursing field (Spratley et al., 2000). Master’s prepared nurses, who
conduct the bulk of clinical education, comprise only 9.6% of the general nurse population. Additionally, as a
group, nursing faculty are older than the rest of the nursing population with a mean age of 49.4 years.
Doctorally prepared faculty holding the ranks of professor, associate professor, and assistant professor had
median ages of 56.3 years, 53.8 years, and 50.4 years, respectively (AACN, 2002a; Spratley et al.).
Because of their older age, 41% of faculty in baccalaureate and higher programs are expected to retire by
2005; among associate degree programs, 24% are expected to retire by 2005 (AACN, 2002a). Third,
economics also account for the nursing faculty shortage. Master’s prepared faculty can command up to
$25,000 more per year working in service settings as compared to colleges (AACN, 2002a; Armstrong,
2002). Last, similar to the entry-level nurse, there are fewer graduations occurring from master’s and
doctoral programs. Graduations from master’s programs have dropped 3.1% and graduations from doctoral
programs decreased 11.1% (AACN, 2002a).

Lack of Geriatric Education and Training

A body of knowledge exists on care of older adults

across the continuum of care settings, but this knowledge has not
necessarily been transmitted into basic nursing programs. Although A body of knowledge exists on
nurses who are in non-obstetric, non-pediatric practices will provide care care of older adults across the
to a predominantly older population, only 23% of baccalaureate nursing continuum of care settings, but
programs nationwide have a required course in geriatric nursing this knowledge has not
(Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). Only thirty baccalaureate necessarily been transmitted into
nursing programs (4%) met all the criteria for an exemplary geriatrics
basic nursing programs.
education (Kovner et al., 2002). Thus, most practicing nurses have
limited preparation to care for elders in any setting: long-term, acute care, community, or rehabilitation.

One of the major reasons for insufficient geriatric nursing content is lack of qualified faculty to teach
geriatrics (Kovner et al., 2002; Rosenfeld et al., 1999; Strumpf, Wollman, & Mezey, 1993). Of the surveyed
schools of nursing, only 42% had a full-time faculty specializing in geriatrics and only 20% reported part-
time faculty with a geriatric specialty. Not only is there a lack of doctorally prepared faculty in geriatrics,
there is also a lack of qualified advanced practice nurses (APNs). Nationally, the number of geriatric APNs
remains small, with only 5,700 nurses certified as geriatric nurse practitioners or geriatric clinical nurse
specialists (Kovner et al.). Kovner and colleagues reported that there are only fifty-four master’s programs
and forty post-master’s programs that prepare advance practice nurses in geriatrics in the United States.
 Thus, there are few nurses with specialized training to provide care to older adults or to provide ongoing
clinical training for entry-level professional nurses.

Suggestions for the Future

The aging of the baby boomers and nursing workforce, the nursing shortage, and the lack of geriatric
knowledge and training among nurses are on a collision course to impact the delivery and quality of health
care for the elderly. A number of suggestions have been made to address the multiple issues, either singly
or in combination, including:

• Focus on the work environment

• Address the ergonomics of the work environment to facilitate delivery of care to an
increasingly dependent patient population
• Promote a positive image of nursing and geriatric nursing in particular
• Provide opportunities for advancement in the service setting and academic setting
• Enhance access to nursing education in general
• Provide education and training in geriatrics to all entry-level nurses
• Develop leadership in geriatric nursing at advanced practice and doctoral levels through
federal and state funding initiatives
• Increase education and training of the existing nursing workforce
• Offer financial incentives to organizations and agencies to provide geriatric care
• Use accrediting and regulatory agencies to strengthen the guidelines and regulations for
training in geriatric care

(AACN, 2001, 2002a; Alliance for Aging Research, 2002; American Hospital Association, 2002; Armstrong,
2002; Berliner & Ginzberg, 2002; Buerhaus, et al., 2000; Joint Commission on Accreditation of Healthcare
Organizations, 2002; Kimball & O’Neil, 2002; Kovner et al., 2002; Scanlon, 2001). The recent passage of
the Nurse Reinvestment Act, while not a panacea, addresses several of these issues by funding grants to
facilities that retain experienced nurses and develop best practices, grants to enhance education in
geriatrics, financial incentives to students who agree to a nurse faculty position after graduation, and public
service announcements that promote the positive image of nursing to a diverse population (Donley et al.,
2002). Examples of several of the above-mentioned suggestions are provided below.

Work Environment

There are aspects of the work environment that can negatively affect

nurses’ job satisfaction that can be addressed without requiring an increase

Providing nurse managers with
the behaviors needed for high
performance can have a positive
impact on the immediate work
environment by improving job
satisfaction.
in the number of RNs. For instance, a strong correlate of job satisfaction
among staff nurses is the type of leadership exhibited by the nurse manager
(Cullen, 1999). The ability to build a team and enhance collaboration among
the members of a unit is an essential skill of a nurse manager. Yet few nurse
managers are provided the skills and training to be an effective leader
(Nursing Leadership Academy, 2002). Providing nurse managers with the
behaviors needed for high performance can have a positive impact on the
immediate work environment by improving job satisfaction.

Ergonomics

Addressing ergonomics in the work environment does require capital resources, which may be limited at this
time of shrinking resources and revenues. Nevertheless, addressing the physical aspects of delivering care is
important. A growing number of companies offer equipment to facilitate delivery of care that promotes both
patient and employee safety. Examples include beds with motors for ease in transportation of patients;
transport boards that require only one person to transfer a patient from bed to cart; and patient lifts built
into ceiling tracks to facilitate transfer from bed to commode or chair, and to facilitate rehabilitation efforts
for patients with unsteady gaits.

Nursing Image

National and regional campaigns have assisted in showing the nursing profession in a positive light. For
example, Johnson & Johnson, a major manufacturer of health care products, has launched the highly visible
Campaign for Nursing’s Future (Johnson & Johnson, 2002). The Campaign for Nursing’s Future provides
scholarships for nursing students, scholarships for nurse educators, television advertising to celebrate
nurses, a web site for those interested in pursuing a nursing career, and recruitment posters and brochures
for high schools and middle schools. An example at a local level includes a half hour television special,
Medical Miracles. Nurses: Celebrating Our Heroes, which showcased nursing at the Cleveland Clinic
Foundation (2002). The show resulted in a number of chat room inquiries following the show from those
interested in pursuing nursing as a career.

Delivery of Care Models

The shortage of registered nurses mandates that nursing leaders in both service and academia re-examine
models of care and processes in the delivery of care. Change in the skill mix of nursing personnel is
unavoidable at this time. Examining ways that non-licensed personnel can perform non-nursing functions to
enhance nurses’ ability to deliver care is paramount. Focus groups conducted at the Cleveland Clinic
Foundation, a 1000-bed tertiary care center, revealed that nurses in all service areas were frustrated with
the time spent in accessing equipment and supplies (Kuhar, Spears, Miller, Ulreich, & Mion, in press). A new
role, the Equipment Technician, who maintains equipment in working order and ensures that unit-based and
room-based supplies are kept stocked, was created. Evaluation of the efficacy of the role revealed that
nurses were pleased with the additional support personnel and that equipment and supplies were no longer
an issue.

Academe-Service Partnerships

Last, it would behoove nurses from service sectors and academic settings

to collaborate on initiatives to address not only the current knowledge and skills needed by nurses to
practice in today’s environment, but also the best practices and systems
for the delivery of care. There are a number of barriers to collaboration,
however. Historically, schools of nursing moved into university and It would behoove nurses from
college settings and away from service settings to promote nursing as a service sectors and academic
profession and as a discipline (Dean & Lee, 1995; Sullinger & Ostmoe, settings to collaborate on
1998). Distancing academe from service has had a downside, however, initiatives to address...the best
by increasing the difficulty of clinical teaching and conducting clinical practices and systems for delivery
research. The logistics of negotiating contracts, facilitating student
of care.
learning, and conducting research are made more complicated by
geographic distances, philosophical differences, and at times, competing goals (Dean & Lee). It is not
uncommon for faculty and students to perceive they are being tolerated or are unwelcome guests by
personnel at clinical sites. Moreover, given the nursing profession’s history, nurse educators in colleges and
universities often consider direct partnerships with service settings as difficult (Sullinger & Ostmoe).

Despite the barriers to collaborative arrangements between service agencies and schools of nursing, this is a
critical time to join resources. One of the strategies necessary for improving quality of nursing care in any
setting is the development and implementation of model practice systems at the provider level (Reinhard &
Stone, 2001). Such model systems imply not only attention to the design of workable quality improvement
programs, but also built-in mechanisms for sharing with others the lessons learned from systematic
experimentation. When there are few resources for quality improvement, the costs may be affordable when
shared among multiple entities (Reinhard & Stone). It follows that the benefits should be shared as well.
Nursing leaders in the academic and service settings need to come forward together, else there is the
danger that others will shape nursing’s future.

Summary

This article reviewed the intersecting forces of the aging population, the nursing workforce shortage, and the
lack of geriatric education and training, all of which will profoundly impact the health care industry unless
steps are taken soon to address the situation. Suggestions to alleviate the gravity of this collision by
addressing areas such as the work environment, ergonomics, nursing image, delivery of care models, and
academe-service partnerships have been discussed. The recently funded Nurse Reinvestment Act will
provide some funding to address the issues considered in this article. However, the situation remains grave.
More is needed to provide the elderly with the care they need, and will continue to need, in the years ahead.

Author

Lorraine C. Mion, PhD, RN

e-mail: lmion@metrohealth.org

Lorraine C. Mion, PhD, RN, received her undergraduate degree from St. John College, Cleveland, OH, and
her graduate and doctoral degrees from Case Western Reserve University. Specializing in geriatric nursing
for over 20 years, Dr. Mion has been actively involved in clinical research and practice, primarily in the acute
care setting. She has authored over 50 peer review articles, several book chapters and has received
National Institutes of Health and foundation grants examining geriatric nursing practices.