Silver Tsunami Research Paper

The Silver Tsunami: The Challenges in Developing an Adequately Trained Nursing Force to Meet the Rising Tide of Elderly Baby Boomers
Carel D. Peterson
San Francisco State University

The Silver Tsunami: The Challenges in Developing an Adequately Trained Nursing Force to Meet the Rising Tide of Elderly Baby Boomers
In what is described as a silver tsunami, the baby boomers (boomers) are turning sixty-five years old at an alarming rate (Heise, et al., 2012). Beginning in 2010 when the first wave hit, the estimated seventy-eight million baby boomers, born between 1945 and 1965, are turning age sixty-five at a rate of approximately 10,000 per day (Heise, et al., 2012). Compounding the wave of boomers reaching age sixty-five, is an
increase in the life expectancy and a decrease in the birthrate of Americans. These factors result in an increasing population of those over sixty-five, and a decreasing population under sixty-five to care for them (Wright, 2005). This rising tide of older Americans is expected to place a strain on the nursing profession due to several factors including: an overall shortage of nursing professionals, a shortage of geriatric-trained nurses, the aging of the existing workforce including nursing faculty, and negative attitudes of nursing students about caring for older people that leads them away from specializing in geriatric nursing (Buerhaus, Staiger, & Auerbach, 2000; Heise, et al., 2012).
As a person reaches old age (sixty-five and older), their physiology changes and as a result, their healthcare needs also change. Some of these changes are visually evident such as body shape, the condition of skin or the graying of hair. What may not be so obvious are the changes that are occurring on the inside. Consideration in the nursing process, from assessment to implementation strategies, must be taken to address the physiologic changes that manifest in old age. Having a highly trained workforce that can address these needs is essential in the coming decades as the baby boom generation ages. This challenge is multifaceted, and so are the possible solutions; yet, despite the tsunami upon us, the nursing profession has yet to provide sufficiently trained resources to care for this wave of aging Americans as they enter old age in unprecedented numbers.
The baby boom generation exerted a strong influence on many facets of American social policy and popular culture. This generation rejected traditional values and redefined what it means to be an American. They were pivotal in the civil rights movement, the free speech movement and women’s rights movement. In addition to political action, this group was also responsible for linking individual behavior to health with the creation of an exercise and health food movement. With a focus on an active and healthy lifestyle, many boomers continue to enjoy recreational activity into old age, earning them a reputation for the generation that refuses to age. As this cohort ages, we are seeing another new movement led by the baby boom generation; a redefinition of what it means to be old. The legendary Bob Dylan song “Forever Young” contains lyrics that reinforce this idea with the blessing “may you stay forever young” (Dylan, 1974). In his essay “Forever Young” Edward F. Ansello writes about the song, to mark Dylan’s 70th birthday suggesting that the message in the song, while intended for Dylan’s young children when originally written nearly forty years ago, applies now to the boomer generation as they age (Ansello, 2011). It is ironic that the characteristics of youth made desirable by the boomers, is now a significant factor in the lack of young nursing students interested in geriatric care because of ageism. In spite of the popular ideas about the graceful aging of the baby boom generation, the reality is that the past sixty-five years also gave rise to an obesity epidemic, a type II diabetes epidemic, the HIV/AIDS epidemic and, as recently reported, boomers now have the distinction of being the largest age group testing positive for Hepatitis C (McHutchison & Bacon, 2005). The challenge of providing quality healthcare for these chronic diseases is another aggravating factor in the silver tsunami.
Nursing plays a leadership role in the health care of all members of society. In an aging society, it is essential that a sufficient number of adequately geriatric-trained nurses are available. Rising to meet an urgent healthcare crisis is nothing new to the nursing profession. For example, during the Civil War the challenge of a severe shortage of nursing care was met by nursing leaders such as Dorothea L. Dix, who created training programs for women who wished to care for wounded soldiers and Clara Barton who created the Red Cross organization (Chitty & Black, 2011). In the aftermath of the Civil War, nursing leaders such as Isabel Hampton-Robb, Lavinia Lloyd Dock, Beford Fenwick, and Florence Nightingale all recognized the need for uniform, scientific training programs resulting in uniform nurse training curriculums emerging (Chitty & Black, 2011). The twin challenges, in 1917, of World War I and the Flu epidemic gave rise to public health nursing, again, led by nurses (Chitty & Black, 2011). As evidenced by these events, we can see that nursing has a long history of rising to the occasion and providing care in times of social need. It seems logical that with the projected increase in population of older Americans that nursing, as a profession, is taking a leading role in providing solutions.
Literature Review
In an integrative review (Goodin, 2003) factors contributing to the nursing shortage were identified. The goal for this meta-analysis of the nursing shortage was to identify the unique factors contributing to the current shortage and discussion of potential solutions. Four of these factors are: (1) the loss of the largest age cohort (boomer nurses) of RNs as they reach retirement age, (2) the loss of boomer nursing faculty as they also retire, (3) the declining trend in enrollment in undergraduate nursing programs, and (4) the poor image of nursing. In response to these factors the author proposes solutions that will provide lasting changes, not quick fixes, to alleviate the current shortage and ensure a steady flow of nurses in the future. She offered many suggestions, but three reasons stand out as being lasting long-term solutions. First is the development of programs to retain current nurses as they age. Second is the development of effective recruitment strategies to attract a steady stream of new nurses. Third is the creation of programs to improve the image of nursing. According to Goodin’s research, the largest cohort of existing RN’s in the workforce entered the profession during the 1960’s and 1970’s and are members of the baby boom generation, born during the period 1946-1964. Since the 1980’s fewer women have entered the profession due in part to the expanded career opportunities for women since that period. Consequently, the largest cohort of nurses is currently reaching retirement age. This means that just as demand for RNs increases, the largest group of these professionals will be leaving the workforce. The departure of this group of experienced professionals also impacts the supply of nursing educators. As nursing educators leave the workforce due to retirement, the availability of training programs for new nurses will also be negatively impacted. Retaining these aging workers and the cohorts that follow requires making the workplace safer and more accessible for aging nurses; being sensitive to the susceptibility of older RN’s to injury and the inability to perform certain tasks while still recognizing the value of their experience. Additionally, Goodin asserts that “employers need to improve personnel policies and benefits, provide opportunities for career advancement, lifelong learning and flexible work schedules” in order to retain the existing workforce (Goodin, 2003, p. 337). Another area essential for the retention of experienced RNs according to Goodin is a competitive compensation package based on the level of preparation, responsibility, and performance.
In the period 1995 to 2003, when this review was conducted, “enrollment in entry level baccalaureate programs in nursing declined by 21.1% and the number of graduating nurses who took the national licensure examination decreased by 26% from 1995 to 2001” and enrollment in graduate programs was also on the decline (Goodin, 2003, p. 335). The main reason given for this decline is the expanded opportunities for women (who make up 90% of the RN workforce) in other professions. Goodin identifies the primary avenue to solving the problem is the active recruitment of new nurses. One study Goodin reviewed found the primary reason the majority of young people make the decision to pursue a career in nursing is “interest and enjoyment in the desire to help people”, and interestingly, the majority did not identify salary as a significant factor in choosing nursing as a career (Goodin, 2003). From this information, Goodin concludes that efforts to recruit young people into the profession should include clear, positive and realistic images about the good work that nurses do to help people on a daily basis.
Using information gathered from a survey conducted in 2001 by the American Nurses Association (ANA), Goodin reports that “seventy-five percent of the respondents stated that the quality of nursing care had declined in their work setting over the past two years” (Goodin, 2003, p.
337). Some of the reasons cited in her paper for the decline in care include: increased patient load, decreased time for direct patient care, increased pressure to accomplish more with less time, and mandatory overtime. For these reasons, nurses reported feeling overburdened, overworked and overstressed and dissatisfied with their jobs. In addition to the general dissatisfaction with the profession, negative stereotypes of nurses such as the “physician’s handmaiden” continue to dominate the public perception of the nursing profession, harming the efforts to recruit new talent into the profession (Goodin, 2003). In order to recruit new nurses, Goodin recommends programs that will expose young people to positive and authentic images of nursing. She uses the coalition of thirty-two nursing and health care organizations who are working together on the campaign, ‘Nurses for a Healthier Tomorrow,’ and Johnson & Johnson’s ‘Campaign for Nursing’s Future’ as good examples of programs that provide this positive “real-life goodness of nursing” messages necessary to accomplish the task. Goodin posits that increasing the value in the eyes of consumers will lead to nursing as a more respected profession in society as a whole and an increase in new nurses entering the workforce as a
result. By analyzing literature published from 1999 to 2001 Goodin concludes that there is indeed a nursing shortage, and that it is not being ignored, however, it is important that nurses take the lead in securing the health of the American healthcare system by ensuring an adequate supply of nurses now and in the future.
Is There a Nursing Shortage? A landmark study published in 2000 by The Journal of the American Medical Association (JAMA) offers an overview of the nursing shortage in that year (Buerhaus, Staiger & Auerbach, 2000). These researchers conducted a cohort retrospective analysis of employment trends to quantify the implications of the aging of the RN workforce. They used data from the US Bureau of the Census Current Population Surveys for the period 1973 through 1998. The results of their research indicated an increase in the average age of working RN’s of 4.5 years from an average age of 37.4 years old in 1983 to 41.9 years old in 1998 (Buerhaus, et al., 2000). Two significant factors creating this aging effect were identified as: the large influx of nurses in the 1960’s and 1970’s who are now reaching retirement age, and the downward trend of younger nurses entering the workforce beginning in the 1980’s. The authors predict that unless a change occurs in their forecasted assumptions these two factors will lead to a shortage of nurses in the decades to come.
In a study published in December of 2011, the same researchers, (Auerbach, Buerhaus & Staiger, 2011) again studied data from the US Census Bureau in order to update their predictions from a decade earlier. This study reported an astonishing increase in the number of registered nurses ages 23-26 of sixty-two percent. This significant change in the workforce composition reverses their earlier predictions of a dire shortage of nurses, although they caution that this trend may not continue and a shortage could indeed still occur given the right circumstances.
For this study the trio used single year birth cohorts as the independent variable in order to evaluate the age of first entry into the RN workforce of existing nurses. The trend analysis revealed a decrease in registered nurses ages 23-26 of almost 50% from the peak in 1979 of 190,000, to below 110,000 in 1991. The decline continued to a low of 102,000, in 2002. However, they found that, since 2002, the trend is now growing and in 2009 the number was up to 165,000, an increase of 62 percent (Auerbach, et al., 2011). From this study it appears that the declining trend of young registered nurses entering the profession has reversed and “the cohorts born in the 1980’s will surpass those born in the 1950’s” (Auerbach, et al., 2011 p. 2287).
The authors then developed a predictive model projecting entry into the workforce using trends from the past five years, and using historical data (since 1965), to “age” the existing workforce in an effort to determine future workforce strength. Using these models they concluded that the workforce will remain stable through 2030. They predict that stability will occur when the recent boom of new nurses enter the workforce replacing the retiring boomers, and that their forecasted increase of new nurses will lead to a steady supply of RNs to meet future needs. So, instead of declining, in absolute and relative to population numbers, their study reveals that it is statistically possible for the nursing workforce to grow at the same relative rate as the population meaning that the projected shortage will not occur. They explain that if entry into nursing were to continue at previous levels, the supply of registered nurses would fall below the projected population need by 15%. If, however, entry into nursing continues to grow at current levels, then the supply of registered nurses will surpass demand in 2030 (Auerbach, et al., 2011). The authors cite successful national recruitment initiatives that aimed to raise awareness of the opportunities and promoting the attractiveness of the profession as being causally linked to the surge in new younger nurses entering the profession. They caution, however, that if the interest in nursing subsides and entry into the profession falls back to the smaller cohorts of 1979-1991, available nursing resources will drop (relative to population) to approximately 12% below today’s level in 2030. They also caution that the actual “need” has not been updated by the Health Resources and Services Administration to include requirements that incorporate future need based on the passage of the 2010 Affordable Care Act and a potential shortage of primary care physicians available to meet these needs or the impact of the greater population of Americans of advanced age that has grown from 13% over age 65 in 2010 to an estimated 19% in 2030 (Auerbach, et al., 2011). All of these needs will impact the nursing workforce in one way or another, primarily requiring advanced education for a significant portion of nurses.
In a third article, published just a few months later, (Staiger, Auerbach, & Buerhaus, 2012) again evaluated the potential nursing shortage. For this study, the researchers looked at the effect of the economic downturn in recent years on the registered nursing workforce. They compared the national unemployment rate for the years 1973-2010 to the actual RN workforce for the year, and they also plotted their predictions for those years using the model developed and explained earlier in this paper. What they found was that in the years that unemployment was high, the actual RN workforce exceeded their predicted numbers and when it was low, the actual numbers were lower than predicted. Quantitatively they found was “an increase of 1 percentage point in the unemployment rate was associated with a 1.2% increase in the size of the RN workforce” (Staiger, et al., 2012). They used this analysis to conclude that the recent surge in the RN workforce is in response to the high unemployment rate and label it a “temporary bubble” (Staiger, et al., 2012). They thus predict that if the expected decline in the unemployment rate occurs, the RN workforce will also decline. Alternately, if the economy stays troubled and the unemployment rate stays stable, we can expect to see stability in the RN workforce as well. They also caution that if the economy recovers that many of the new RNs will exit the workforce. These new RNs leaving the workforce along with the exit of the baby-boomer nurses who have been postponing retirement, will leave us with a dire shortage, at the same time as 32 million more Americans obtain health insurance coverage due to the Affordable Care Plan. The authors warn that policy makers should not be fooled by the current lack of a nursing shortage. They predict that by 2020 the demand for nurses will cleanly outstrip supply and that making recruitment of new nurses a priority in spite of this short term bubble is essential.
Whether or not a shortage of RNs will occur in the coming years is now open to debate and dependent on a number of factors. What is certain, however, is that this topic will be followed closely in the years to come and every effort will be made to ensure that an adequate supply of nurses is available to care for an aging America. Regardless of the supply of nurses engaged in the workforce, the most important factor in developing the workforce for the future will be having nurses trained in caring for older adults.
Providing Competent Care for the Tsunami of Older Americans
In their review of policy initiatives, Susan Crocker Houde and Karen Devereaux Melillo, argue that an expanded workforce prepared to provide care for the expected increase in older adults is essential (Houde & Melillo, 2009). They present the results of their review of policy initiatives that address the projected shortage of a geriatric workforce and policy initiatives by professional nursing associations aimed at enhancing the gerontological nursing workforce. Of the policies reviewed, The Institute of Medicine (IOM) 2008 report “Retooling for an Aging America: Building the Health Care Workforce”, stands out as the primary professional policy leader in this area. The Committee recommended the following three approaches: (1) enhance the competence of all individuals in the delivery of geriatric care, (2) increase the recruitment and retention of geriatric specialists and caregivers, and (3) redesign models of care and broaden provider and patient roles to achieve greater flexibility. Barriers to the education necessary to implement the first of these recommendations include the lack of faculty and the consistent curriculum required to tie education to certification. Challenges to increasing recruitment and retention of nursing professionals in this specialty include financial incentives such as scholarships and loan forgiveness programs and reexamining reimbursement rates for geriatric care. Improvement in job environments was also cited as necessary to entice new nurses to choose geriatrics as a specialty. In tackling the redesign of models of care, changing the reimbursement methods of Medicare was identified as the biggest challenge. Targeting prevention, long-term care, palliative care and rethinking the use of the existing health care workforce in providing services are also critical goals. Their research highlights the work of private foundations such as the John A. Harford Foundation and professional nursing organizations such as the American Academy of Nursing, and the American Association of Colleges of Nursing that are working tirelessly to promote initiatives to address the shortage of gerontological nurses and allied healthcare workers.
The John A. Hartford Foundation has funded a project in partnership with the American Colleges of Nursing that is working to create nationally recognized competencies for adult-gerontology nurse practitioners and clinical specialist. The foundation is also working in partnership with the American Academy of Nursing, by funding a program aimed at education and nationally recognized and consistent competencies for geropsychiatric nurse specialists of all levels. The Robert Wood Johnson Foundation has funded a project aimed at exploring strategies for retaining aging nurses, valuing the wisdom brought by experienced nurses, while creating a work environment that takes into account physical limitations to allows these older nurses to continue to pursue their careers as they age.
In her work Elaine Amella, presents the way in which aging alters health problems in older adults (Amella, 2003). As the population of older adults increases, the ability to accurately assess and care for them will become essential skills for the nurse to master. Some of the ways in which signs and symptoms of illness are altered in old age include: changes in mental status, an altered sensation of pain, vague rather than acute symptoms, inability to perform certain activities, falls, dehydration, loss of appetite, and unusual reactions to medications (Amella, 2003). Although mental status may change as we age, a sudden change in mental status is often a symptom of a more severe health problem. Dehydration is also a common issue for older adults because of the decrease in muscle mass and thus a decrease in intracellular water content (Amella, 2003). The nurse is the front line provider in the provision of health care, being able to accurately assess a patient’s health status is crucial. Taking into account the alterations of these and other age specific alterations in disease presentation in is the reason that so much emphasis is focused on training of nurses in the care of older adults.
Clearly the demand for professionally trained geriatric nursing specialists is critical due to the aging of America, however the need for specific education among all nurses in caring for the older adult is also essential because of the higher percentage of the population that will be over age 65 in the coming years.
So, how do we as a society develop an adequate number and professionally competent nursing workforce to meet the challenges presented by our aging nation? The answer to that question is beyond the scope of this paper, but the challenge has been taken up by many groups including The John A. Hartford Foundation, a philanthropic foundation with the mission to “improve the health of older Americans” (The John A. Hartford Foundation, 2011). The introduction of geriatric coursework in nursing programs in an effort to increase the competence of all newly trained nurses led by the John A. Harford Foundation is one response to the challenge.
The work of four nursing faculty members from Brigham Young University, College of Nursing is an excellent example of how nursing educators are including geriatric coursework into the general nursing curriculum (Heise, Johnsen, Himes & Wing, 2012). The team wrote an article reporting on their experience championing gerontology content at their school. One aspect of the work they did was to survey the nursing faculty to assess the degree which gerontology content was included in the nursing program. The researchers then mailed resources to the faculty that could be added to the nursing courses they were teaching including: PowerPoint slides; case studies; and a listing of internet links to sites such as the John A. Hartford Foundation, and the National League for Nursing. The following year they resurveyed the faculty to determine to what degree the materials they sent out were used in the classroom. They discovered that some of the faculty took advantage of the resources and that one professor even changed the textbook used for the course to one that included a gerontology section in each chapter. In addition, they developed a “Course Council” that included student representatives and faculty which met on a monthly basis to discuss student feelings about older adults. Based on feedback from these sessions, course content was modified to enhance student learning about caring for older adults. Didactic activities were designed to integrate lecture material and to allow students to experience what older adults feel. For example, in a class about polypharmacy, students viewed a movie demonstrating the difficulty of older adults in managing complex medication regimes then took part in an activity to reinforce the concept. Dr. Vickie Johnsen developed a pill sorting exercise, where each student was given a bag of at least 20 “pills” (different color and shaped candy), then the students were instructed to sort the “medications”. To make the exercise even more realistic, each student was then given a “diagnosis” like a stroke with loss of use of a hand or glaucoma with loss of sight and asked to sort the medication again. Other exercises included writing a reflective paper about their experience working with an older adult during clinical. The authors found that the students were able to deepen their understanding of older adults and valued these experiences. In concluding the article, the authors emphasized the importance of allowing young nursing students to engage in activities that change their perceptions of older adults so they will see the benefits of working with them in the future and we as a society can begin to build a workforce that has the capability and the capacity to provide nursing care for older adults.
Active campaigns to attract new nurses forestalled the concerns of an shortage in the 1990’s and early 2000’s making predictions of a shortage, potentially, a thing of the past. However, as the economy continues to recover, the shortage is predicted to reemerge. It is important to keep in mind that regardless of whether we have a shortage in absolute numbers of nurses, the population of our country is getting older and the nursing profession will need to adapt how it delivers care to these older Americans. How nurses deliver care is evolving and the skill and willingness to work with older adults is very much still a concern. Perhaps the same strategies that worked to produce the surge of new nurses in the first decade of the century will transfer to creating a sustainable workforce adequately trained to care for older adults.
Recommendations
The demographics of American are changing and that the percentage of those over age 65 is projected to increase by 135% between 2000 and 2050 and the population of the very old (over 85 years of age) is projected to grow by 350% in the same period (Wiener & Tilly, 2002). The real challenge for the nursing profession in the near term is to ensure an adequate supply of nursing professionals trained to meet the needs of the geriatric patient. In order to meet this challenge, a multi-faceted approach is required. First, it is essential that we retool the existing workforce to include continuing education programs that provide currently licensed RNs expertise in caring for the geriatric patient. Second, a modification of the existing RN training curriculum is recommended that would include both specific geriatric theory and clinical courses, and an integration of geriatric-care content across the nursing curriculum. Another recommendation is to make an investment in the creation of more advanced degree programs to create faculty that are enthusiastic about the special needs in caring for older adults. The national recruitment initiatives aimed at raising awareness of the opportunities and promoting the attractiveness of the nursing profession in general have been wildly successful. A logical extension of this strategy is to replicate the same model in promoting the benefits of specialization in geriatric nursing.
The very nature of the nursing profession, caring for people, has always been the primary motivation for implementing solutions that address emerging health care crisis. It is up to us, as a caring professional community, to provide viable solutions to the impending silver tsunami.

References
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