让照护老年人成为护士们今天、明天和永远的选择

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The current nursing shortage, whether it is a true shortage of registered nurses or a shortfall in distribution of our available workforce, is inescapable. We read about it, we hear about it, and we live it. The effects of the shortage are most often described in terms of hospitals, focused on those facilities in urban and suburban communities. That focus neglects the place where nurse staffing is always under threat and is now severely compromised: nursing homes. Currently, approximately 50% of nursing homes across the nation report shortages post impact of COVID-19.1 Nursing homes in rural areas are experiencing even greater duress with the current shortage.2 While hospitals, clinics, and all clinical agencies are contending with significant shortfalls in their nurse workforce, nursing homes fell even farther behind in meeting staffing needs during the COVID-19 pandemic.

Several factors contributed to nurse shortages prior to COVID-19. Factors specific to each generation's workforce often contributed to this and earlier shortages. Nurses of the Baby Boom generation retiring in this and the coming decade.3 Their retirement, coupled with the escalating demand for nurses, is not matched by the numbers of people graduating from nursing schools. Additionally, new graduate nurses may move quickly and easily into advanced practice education. Nurses who do so are potentially mitigating the shortage of primary health care providers. Nevertheless, they are simultaneously contributing to the wider nursing shortage. Lastly, workplace concerns like low staffing levels, low morale, and subsequent burnout are pushing nurses out of healthcare entirely.

Issues that keep nurses in nursing homes and what drives them out are unsurprising and much like those that affect nurses in other settings. Not-for-profit nursing homes, those with less turnover in administration, and those that have better staff engagement fare better. Higher regional unemployment and a larger proportion of people living with dementia are among the more unusual factors that help retain nurses. Sadly, but not surprisingly, lower salaries, lack of support for personal health, and bullying and incivility all contribute to nurses leaving nursing homes.4,5 Some factors influencing the nursing shortage in nursing homes are specific to that setting. Long-term care is beset by a long history of punitive organizational and regulatory cultures affecting nurses and residents alike. Other factors driving the shortage in this setting are, however, common to all nurses – including underpayment and limited support for personal mental and physical wellbeing. Organizational and cultural forces contributing to the nurse shortage in nursing homes, whether specific to long-term care or widespread throughout our healthcare system, should have been redressed long ago but persist unmitigated.

Enter the pandemic. Nurses are now deemed ‘heroes’ in social and news media. While such accolades might reinforce nurses’ commitment to patient care, they do nothing to address persistent problems that continue to erode nurses’ work environments, job satisfaction, and well-being. More than ever, nurses are burnt out as they try to care for increasingly complex patients with limited resources. The mismatch between ‘hero’ and daily workload is frequently intolerable. Critically, nurses working in nursing homes were further harmed by the public adulation of nurses. The acclaim for nurse ‘heroes’ frequently zeroes in on those in acute care settings, extending longstanding neglect of those nurses working in long-term care settings. In those settings, resources are limited and have been so for decades. Moreover, complexity characterizes all residents these nurses’ care. They are doing far more with far less. As the pandemic drags on, new social factors are emerging as influences in the nursing shortage. The rise of travel and agency opportunities is further widening the salary gap long felt by nursing home staff. Stressors arising from personal demands in childcare, eldercare, and personal health concerns are escalating in salience as nurses consider whether to leave the profession. More than ever, nurses employed in nursing homes are asking ‘why should I stay?’ and are unlikely to encourage students and colleagues to join them in long-term care.

Alleviating this or any nursing shortage requires change at many levels. System-wide changes must go beyond simply helping staff to feel supported for a shift, a day, or a week. No evidence suggests any long-term effects of token gestures like meals during a shift or gifts of swag. Policy changes must include robust strategies to retain the current nursing workforce. Equity in salary and benefits are paramount. Policy guaranteeing funding and supply chains are necessary to ensure adequate resources for safe nursing practice in all settings, especially nursing homes. Lastly, nursing homes specifically need policy and practice changes to optimize scope of practice and provide around-the-clock professional nurse leadership.

Scope of practice considerations for all members of the nursing team currently limits entry into and retention in professional nursing. Registered nurses (RNs) are frequently prevented from practicing to the full scope of their licensure, hindered by requirements to communicate with providers about management of common clinical finding in the absence of protocols and procedures that support them providing care at the top of their scope. For instance, addressing gaps in care with nursing protocols that facilitate treatment for common problems such as constipation, chronic wounds, and chronic pain amplifies autonomy, enabling RNs to provide innovative care without consulting a provider. Critically, such protocols save precious time for residents and allows RNs to lead in care rather than relying on a provider who likely holds less expertise than they in treating those problems. Similarly, limited scope of practice for certified nursing assistants (CNAs) – nursing team members who are the veritable backbone of care in any nursing home – too often fails to match resident need or CNA capacity. For example, training CNAs and altering certification to enable them to give medications addresses unmet clinical needs and maximizes their capacity to contribute to care. Initiatives focused on improving the extent to which RNs and CNAs can provide high quality, holistic care for residents in nursing homes is essential to both the residents’ health and to resolving issues that underly the nursing shortage.

Parallel concerns exist in scope for advanced practice nurses (APNs). Policies that ensure APNs can practice to the full scope of their licenses are necessary to ensure residents receive optimal care. Such policies are likely to stem the shortage of APNs in nursing homes by optimizing APN's contributions to access and quality of care for older adults. Expanding efforts to overcome limitations of state-specific licensure offers additional advantages for advancing and ensuring appropriate scope of practice. The Nursing Licensure Compact (NLC), originally approved in 2000, is an agreement between states that allows nurses to have one license but the ability to practice in other states that are part of the agreement. In 2020 a similar process was adopted for Advanced Practice Nurses 2020 referred to as the APRN Compact {National State Boards of Nursing, 2021 #13}. The APRN Compact allows an advanced practice registered nurse to hold one multistate license with a privilege to practice in other compact states. All state boards of nursing must take advantage of both compacts in parallel with efforts to promote APN scope of practice, making practice in any setting – including nursing homes – more attractive and fulfilling.

Addressing the nursing shortage specific to nursing homes must couch advances in policies, procedures, and practices in robust culture change. Reasons to specialize in geriatrics and work with older adults in nursing homes and other settings are clouded by widely accepted ageism, discrimination that affects older adults and the nurses who might choose to care for them. Over the past decades, nurse leaders have designed different programs to draw people into nursing and nurses into geriatrics. The Teaching Nursing Home Model is back in the form of in the Pennsylvania Teaching Nursing Home Pilot 。 Other local efforts include schools of nursing offering robust clinical rotations in nursing homes and programs providing opportunities to students to work in long-term care facilities. Conversely, some long-term care companies offer scholarships that attract students with financial support, training in their nursing homes, and employment or residencies after graduation. All such programs offer some benefits and are likely to achieve success, in concert with other measures, when designed with consideration for local factors relevant to nursing and long-term care.

Dismantling the ageism that persists in nursing and our wider society and resolving issues underlying the nursing shortage in nursing homes requires widespread culture change, undoing mistaken impressions about working in a nursing home and building positive and realistic understandings of what it is to be old today. Ageism intersects with and promotes other forms of discrimination, including racism and gender discrimination along with healthism and ableism. Dismantling all forms of discrimination is critically relevant in nursing homes, with their highly diverse direct care workforce. Creating inclusive working and living environments must be a high priority for all to thrive and to build diverse leadership capacity in long-term care to better serve our increasingly diverse communities.

The many advantages of working in long-term care – from job security to learning from those older adults in our care – are constantly clouded by ill-conceived ageist myths. Consider two myths frequently held up as reasons to avoid working in nursing homes. Myth 1: nursing home practice is boring and repetitive. Truth? The level of complexity and rarity seen in care for nursing home residents is unmatched. Rare conditions are often commonplace. Multi-morbidity is ubiquitous. Technology is limited. Nursing home nurses must rely on astute observations, an orientation to learning constantly, and strong teamwork to ensure optimal care. Myth 2: caring for older people is sad and uninteresting. Truth? Caring for people in their 80’s, 90’s, and beyond is uplifting, educational, and fun. Trust on this last point – we have an astounding 166 years of geriatric experience among us! Older adults teach us all about resilience and how to bounce back, survive, and thrive even in the worst of times. They remind us that dance parties, walking with someone to dinner, and enjoying a movie or a hobby with friends are ageless joys. You can do all those things in a nursing home – and much more, finding just as much enjoyment in them inside a nursing home as outside.

Today's nursing shortage is not new news to any of us, especially not to those of us who work in geriatrics and long-term care. We all have an investment in resolving the nursing shortage and making care for older people the choice of nurses for today, tomorrow, and forever. With the universal hope of growing old ourselves, we must reimagine nursing and nursing homes for our aging society. Our own healthcare depends on it. We know that nurses everywhere and especially our colleagues in long-term care are truly heroes, but no hero can work against adversity forever. We must all act now to effect necessary change locally and nationally. Our future is in our hands.

全文翻译（仅供参考）

目前的护理短缺，无论是真正的注册护士短缺，还是我们现有劳动力的分配短缺，都是不可避免的。我们读到了它，听到了它，我们也生活在其中。短缺的影响最常被描述在医院方面，集中在城市和郊区社区的那些设施上。这种关注忽视了护士人手一直受到威胁，而且现在严重受损的地方：疗养院。目前，全国约有50%的疗养院报告在COVID-19影响后出现了人员短缺。

有几个因素造成了COVID-19之前的护士短缺。每一代人的劳动力所特有的因素往往导致了这次和以前的短缺。他们的退休，加上对护士的需求不断增加，与从护校毕业的人数不相匹配。此外，新毕业的护士可以迅速和容易地进入高级实践教育。这样做的护士有可能缓解初级卫生保健提供者的短缺问题。然而，他们同时也在为更广泛的护士短缺问题做贡献。最后，工作场所的问题，如人员配置水平低，士气低落，以及随后的职业倦怠，正在将护士完全挤出医疗保健领域。

让护士留在疗养院的问题和驱使他们离开的问题并不令人惊讶，与影响其他环境的护士的问题很相似。非营利性的养老院、行政部门人员流动较少的养老院以及员工参与度较高的养老院表现较好。较高的地区失业率和较大比例的痴呆症患者是帮助留住护士的较不寻常的因素之一。可悲的是，但并不奇怪，较低的工资，缺乏对个人健康的支持，以及欺凌和不文明行为，都有助于护士离开疗养院。长期护理被长期的惩罚性组织和监管文化所困扰，对护士和居民都有影响。然而，推动这种环境下护士短缺的其他因素也是所有护士所共有的--包括报酬过低和对个人身心健康的支持有限。导致养老院护士短缺的组织和文化力量，不管是长期护理所特有的还是我们整个医疗系统普遍存在的，都应该在很久以前得到纠正，但却一直没有得到缓解。

进入大流行的时代。护士现在被社会和新闻媒体视为 "英雄"。虽然这样的赞誉可能会加强护士对病人护理的承诺，但它们对解决持续侵蚀护士的工作环境、工作满意度和幸福感的问题毫无帮助。护士们比以往任何时候都更加焦头烂额，因为他们试图用有限的资源来照顾日益复杂的病人。英雄 "和日常工作量之间的不匹配常常让人无法忍受。关键是，在养老院工作的护士受到公众对护士的崇拜的进一步伤害。对护士'英雄'的赞誉经常集中在急症护理环境中的护士身上，使那些在长期护理环境中工作的护士长期被忽视。在这些环境中，资源是有限的，几十年来都是如此。此外，这些护士护理的所有居民都很复杂。他们正在用更少的钱做更多的事。随着大流行病的拖延，新的社会因素正在出现，成为影响护理短缺的因素。旅行和代理机会的增加，进一步扩大了养老院工作人员长期以来感受到的工资差距。在护士们考虑是否离开这个行业的时候，因照顾孩子、照顾老人和个人健康问题等个人需求而产生的压力也越来越突出。受雇于养老院的护士比以往任何时候都在问 "我为什么要留下来？"他们不太可能鼓励学生和同事加入他们的长期护理工作。

缓解这种或任何护理短缺需要在许多层面进行变革。全系统的变革必须超越简单地帮助员工感到被支持的一个班次、一天或一个星期。没有证据表明，像轮班时吃饭或赠送礼品这样的象征性姿态会产生长期影响。政策变化必须包括强有力的战略，以保留现有的护理队伍。工资和福利的公平是最重要的。保证资金和供应链的政策是必要的，以确保在所有环境下有足够的资源进行安全护理实践，特别是养老院。最后，疗养院特别需要政策和实践的改变，以优化实践范围，提供全天候的专业护士领导。

护理团队所有成员的执业范围考虑目前限制了进入和保留专业护理工作。注册护士(RNs)经常被阻止在其执照的全部范围内执业，在缺乏支持他们在其范围内提供护理的协议和程序的情况下，与提供者就常见的临床发现的管理进行沟通的要求阻碍了他们。例如，用护理协议解决护理中的差距，促进治疗常见的问题，如便秘、慢性伤口和慢性疼痛，扩大了自主权，使护士在不咨询提供者的情况下提供创新护理。重要的是，这种协议为居民节省了宝贵的时间，并允许护士领导护理工作，而不是依赖在治疗这些问题上可能比他们拥有更少专业知识的提供者。同样，注册护理助理（CNA）--护理团队成员是任何养老院名副其实的护理骨干--的有限执业范围往往不能满足居民的需要或CNA的能力。例如，培训CNA和改变认证，使他们能够提供药物，解决未满足的临床需求，并最大限度地提高他们对护理的能力。专注于提高护士和CNA为养老院居民提供高质量的整体护理的程度，对居民的健康和解决护士短缺的问题至关重要。

高级执业护士(APNs)的范围也存在类似的问题。有必要制定政策，确保高级护士能够在其执照的全部范围内执业，以确保居民得到最佳护理。这样的政策有可能通过优化APN对老年人获得护理和护理质量的贡献来阻止养老院中APN的短缺。扩大努力，克服各州执照的限制，为推进和确保适当的执业范围提供了额外的优势。最初于2000年批准的《护理许可证协议》(NLC)是各州之间的一项协议，允许护士拥有一个许可证，但能够在属于该协议的其他州执业。2020年，一个类似的程序被采用，适用于2020年的高级执业护士，被称为APRN契约{全国各州护理委员会，2021 #13}。高级实践注册护士契约允许高级实践注册护士持有一个多州执照，并享有在其他契约州执业的特权。所有州的护理委员会都必须利用这两个契约，同时努力促进高级注册护士的执业范围，使在任何环境下--包括养老院--的执业更有吸引力和成就感。

解决养老院特有的护士短缺问题，必须联系政策、程序和实践的进步，进行强有力的文化变革。在养老院和其他环境中专攻老年医学和为老年人工作的理由被广泛接受的年龄歧视所掩盖，这种歧视影响到老年人和可能选择照顾他们的护士。在过去的几十年里，护士长们设计了不同的方案来吸引人们从事护理工作和护士从事老年病学工作。在宾夕法尼亚州教学护理院试点项目中，教学护理院模式又出现了。其他地方的努力包括护理学校在养老院提供强大的临床轮训，以及为学生提供在长期护理机构工作的机会的项目。相反，一些长期护理公司提供奖学金，以财政支持吸引学生，在他们的护理院培训，毕业后就业或住院。所有这些计划都提供了一些好处，如果在设计时考虑到与护理和长期护理有关的当地因素，那么这些计划与其他措施一起，很可能会获得成功。

消除在护理和我们更广泛的社会中持续存在的年龄歧视，解决养老院护理人员短缺的根本问题，需要广泛的文化变革，消除对养老院工作的错误印象，建立对今天的老龄化的积极和现实的理解。年龄歧视与其他形式的歧视交织在一起，并促进了其他形式的歧视，包括种族主义和性别歧视，以及健康主义和能力主义。拆除所有形式的歧视对养老院来说是至关重要的，因为养老院的直接护理人员高度多样化。创造包容性的工作和生活环境必须是一个高度优先事项，以便所有人都能茁壮成长，并在长期护理中建立多样化的领导能力，更好地服务于我们日益多样化的社区。

在长期护理行业工作的许多优势--从工作保障到向我们所护理的老年人学习--不断被错误的年龄歧视神话所掩盖。请看两个经常被认为是避免在疗养院工作的理由的神话。神话1：养老院的工作是枯燥和重复的。真相是什么？护理养老院居民的复杂程度和罕见程度是无可比拟的。罕见的情况往往很常见。多病症无处不在。技术是有限的。疗养院的护士必须依靠敏锐的观察力，不断学习的方向，以及强大的团队合作来确保最佳的护理。误解2：护理老年人是悲伤和无趣的。真相是什么？照顾80岁、90岁及以上的人是令人振奋的，有教育意义的，而且很有趣。请相信这最后一点--我们中间有惊人的166年的老年病经验! 老年人教给我们所有关于复原力的知识，以及如何在最困难的时候反弹、生存和发展。他们提醒我们，跳舞聚会、与人散步去吃饭、与朋友一起享受电影或爱好是不老的快乐。你可以在疗养院里做所有这些事情--以及更多的事情，在疗养院里和在外面一样能找到这些乐趣。

今天的护理人员短缺对我们任何人来说都不是什么新鲜事，尤其是对我们这些从事老年医学和长期护理的人来说。我们都有责任解决护士短缺的问题，并使照顾老年人成为护士们今天、明天和永远的选择。带着自己变老的普遍希望，我们必须为我们的老龄化社会重新设想护理和养老院。我们自己的医疗保健取决于此。我们知道，各地的护士，特别是我们长期护理的同事是真正的英雄，但没有一个英雄可以永远在逆境中工作。我们现在都必须采取行动，在当地和全国范围内实现必要的变革。我们的未来就在我们手中。

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