Introduction

The current nursing shortage, whether it is a true shortage of RNs or a shortfall in distribution of our available workforce, is inescapable. We read about it, hear about it, and 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 the coronavirus disease 2019 (COVID-19) pandemic (Gibson & Greene, 2020). Nursing homes in rural areas are experiencing even greater duress with the current shortage (Yang et al., 2021). Although 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 nursing shortages prior to the COVID-19 pandemic. Factors specific to each generation's workforce also contributed to the current and earlier shortages. Nurses of the Baby Boom generation are retiring in this and the coming decade (Mossburg, 2018). Their retirement, coupled with the escalating demand for nurses, is not matched by the numbers of people graduating from nursing schools. In addition, 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, such as low staffing levels, low morale, and subsequent burnout, are pushing nurses out of health care entirely.

Factors that keep nurses in nursing homes and issues that drive 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 (Kennedy et al., 2021; Kolanowski et al., 2021). 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 well-being. Organizational and cultural forces contributing to the nursing shortage in nursing homes, whether specific to long-term care or widespread throughout our health care system, should have been redressed long ago but persist unmitigated.

Enter the pandemic. Nurses are now deemed “heroes” in social and news media. Although 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 for decades. Moreover, complexity characterizes the needs of all residents under 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 are 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 feel supported for a shift, a day, or a week. No evidence suggests any long-term effects of token gestures, such as meals during a shift or gifts of swag. Policy changes must include robust strategies to retain the current nursing work-force. Equity in salary and benefits is paramount. Policies 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. 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 findings 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 allow 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 are essential to residents' health and 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 APNs' contributions to access and quality of care for older adults. Expanding efforts to overcome limitations of state-specific licensure offer additional advantages for advancing and ensuring appropriate scope of practice. The Nursing Licensure Compact, 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 APNs, referred to as the APRN Compact (access https://www.ncsbn.org/aprn-compact.htm). The APRN Compact allows an APRN 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 express 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 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 the Pennsylvania Teaching Nursing Home Pilot (access https://www.jhf.org/whatwedo/whatwedo-2/projects-and-programs). Other local efforts include nursing schools 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. Multimorbidity is ubiquitous. Technology is limited. Nursing home nurses must rely on astute observations, an orientation to learning constantly, and strong team-work to ensure optimal care. Myth 2: caring for older people is sad and uninteresting. Truth? Caring for people in their 80s, 90s, and beyond is uplifting, educational, and fun. Trust us 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 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 health care 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.

Donna M. Fick, PhD, RN, FAAN, FGSA

Editor, Journal of Gerontological Nursing

Professor, Pennsylvania State University University

Park, Pennsylvania

Sarah H. Kagan, PhD, RN, FAAN, FGSA

Professor of Gerontological Nursing

University of Pennsylvania

Philadelphia, Pennsylvania

Barbara Resnick, PhD, CRNP, FAAN, FGSA

Editor, Geriatric Nursing

Professor, University of Maryland

Baltimore, Maryland

Heather M. Young, PhD, RN, FAAN, FGSA

Editor, Research in Gerontological Nursing

Professor and Dean Emerita, University of

California Davis

Davis, California

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中文翻译：

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让照顾老年人成为今天、明天和永远的护士的选择

介绍

当前的护理短缺，无论是真正的注册护士短缺还是我们可用劳动力分配的短缺，都是不可避免的。我们读到它，听到它，并活在它身上。短缺的影响通常用医院来描述，重点是城市和郊区社区的那些设施。这种关注忽视了护士人员总是受到威胁并且现在受到严重损害的地方：疗养院。目前，全国约有 50% 的疗养院报告在 2019 年冠状病毒病 (COVID-19) 大流行的影响后出现短缺（Gibson & Greene，2020）。由于目前的短缺，农村地区的疗养院面临着更大的压力（Yang 等人，2021 年）。尽管医院、诊所和所有临床机构都在努力应对护士队伍的严重短缺，

在 COVID-19 大流行之前，有几个因素导致了护理短缺。每一代劳动力的特定因素也导致了当前和早期的短缺。婴儿潮一代的护士将在这个和未来十年退休（Mossburg，2018 年）。他们的退休，加上对护士的需求不断增加，与从护士学校毕业的人数不匹配。此外，新毕业的护士可以快速轻松地进入高级实践教育。这样做的护士可能会缓解初级卫生保健提供者的短缺。然而，它们同时也导致了更广泛的护理短缺。最后，工作场所的担忧，例如人员配备水平低、士气低落和随后的倦怠，正在将护士完全排除在医疗保健之外。

让护士留在疗养院的因素以及驱使他们离开的问题并不令人惊讶，这与影响其他环境中护士的因素非常相似。非营利性疗养院、管理人员流动较少的疗养院以及员工敬业度较高的疗养院会更好。更高的地区失业率和更大比例的痴呆症患者是有助于留住护士的更不寻常的因素。可悲但不足为奇的是，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会导致护士离开疗养院（Kennedy 等人，2021 年；Kolanowski 等人，2021 年）。影响疗养院护理人员短缺的一些因素是特定于该环境的。长期护理受到影响护士和居民的惩罚性组织和监管文化的长期困扰。然而，导致这种情况下短缺的其他因素对所有护士来说都是共同的——包括工资过低和对个人身心健康的支持有限。导致疗养院护理短缺的组织和文化力量，无论是针对长期护理还是在我们的医疗保健系统中普遍存在，早就应该得到纠正，但仍然没有得到缓解。

进入大流行。护士现在被视为社交媒体和新闻媒体中的“英雄”。尽管这些荣誉可能会加强护士对患者护理的承诺，但它们无助于解决持续侵蚀护士工作环境、工作满意度和幸福感的持续存在的问题。护士比以往任何时候都更加精疲力尽，因为他们试图用有限的资源照顾日益复杂的患者。英雄和日常工作量之间的不匹配经常是无法容忍的。至关重要的是，在疗养院工作的护士受到公众对护士的奉承的进一步伤害。对护士英雄的赞誉经常集中在那些在急性护理环境中的人身上，延长了对那些在长期护理环境中工作的护士的长期忽视。在这些环境中，资源是有限的，而且已经持续了几十年。而且，复杂性是这些护士照顾下所有居民的需求的特征。他们用更少的资源做更多的事情。随着大流行的蔓延，新的社会因素正在成为护理短缺的影响因素。旅行和代理机会的增加进一步扩大了疗养院工作人员长期以来的工资差距。随着护士考虑是否离开这个行业，儿童保育、老人保育和个人健康问题的个人需求所产生的压力正变得越来越突出。在疗养院工作的护士比以往任何时候都在问“我为什么要留下来？” 并且不太可能鼓励学生和同事加入他们的长期护理。旅行和代理机会的增加进一步扩大了疗养院工作人员长期以来的工资差距。随着护士考虑是否离开这个行业，儿童保育、老人保育和个人健康问题的个人需求所产生的压力正变得越来越突出。在疗养院工作的护士比以往任何时候都在问“我为什么要留下来？” 并且不太可能鼓励学生和同事加入他们的长期护理。旅行和代理机会的增加进一步扩大了疗养院工作人员长期以来的工资差距。随着护士考虑是否离开这个行业，儿童保育、老人保育和个人健康问题的个人需求所产生的压力正变得越来越突出。在疗养院工作的护士比以往任何时候都在问“我为什么要留下来？” 并且不太可能鼓励学生和同事加入他们的长期护理。在疗养院工作的护士都在问“我为什么要留下来？” 并且不太可能鼓励学生和同事加入他们的长期护理。在疗养院工作的护士都在问“我为什么要留下来？” 并且不太可能鼓励学生和同事加入他们的长期护理。

缓解这种或任何护理短缺需要在许多层面上进行改变。系统范围内的变化必须超越简单地帮助员工在轮班、一天或一周内感受到支持。没有证据表明象征性姿态的任何长期影响，例如轮班期间的用餐或赃物礼物。政策变化必须包括强有力的战略，以保留当前的护理人员。工资和福利的公平是最重要的。保证资金和供应链的政策对于确保在所有环境中，尤其是疗养院有足够的资源进行安全护理实践是必要的。最后，疗养院特别需要改变政策和实践，以优化实践范围并提供全天候的专业护士领导。

护理团队所有成员的实践范围考虑目前限制了专业护理的进入和保留。RN 经常被阻止在其执照的全部范围内执业，因为要求与提供者就常见临床发现的管理进行沟通，而没有支持他们在其范围内提供最高护理的协议和程序。例如，通过有助于治疗便秘、慢性伤口和慢性疼痛等常见问题的护理方案来解决护理方面的差距，从而增强自主权，使 RN 能够在不咨询提供者的情况下提供创新护理。至关重要的是，这样的协议为住院医师节省了宝贵的时间，并允许注册护士领导护理，而不是依赖可能比他们在治疗这些问题方面拥有更少专业知识的提供者。同样，认证护理助理 (CNA) 的执业范围有限——护理团队成员是任何疗养院名副其实的护理骨干——往往无法满足居民的需求或 CNA 的能力。例如，培训 CNA 并更改认证以使他们能够提供药物以解决未满足的临床需求并最大限度地提高他们为护理做出贡献的能力。旨在提高 RN 和 CNA 为疗养院居民提供高质量、全面护理的程度的举措对于居民的健康和解决护理短缺的问题至关重要。认证护理助理 (CNA) 的执业范围有限——护理团队成员是任何疗养院真正的护理骨干——往往无法满足居民的需求或 CNA 的能力。例如，培训 CNA 并更改认证以使他们能够提供药物以解决未满足的临床需求并最大限度地提高他们为护理做出贡献的能力。旨在提高 RN 和 CNA 为疗养院居民提供高质量、全面护理的程度的举措对于居民的健康和解决护理短缺的问题至关重要。认证护理助理 (CNA) 的执业范围有限——护理团队成员是任何疗养院真正的护理骨干——往往无法满足居民的需求或 CNA 的能力。例如，培训 CNA 并更改认证以使他们能够提供药物以解决未满足的临床需求并最大限度地提高他们为护理做出贡献的能力。旨在提高 RN 和 CNA 为疗养院居民提供高质量、全面护理的程度的举措对于居民的健康和解决护理短缺的问题至关重要。培训 CNA 并更改认证以使他们能够提供药物以解决未满足的临床需求并最大限度地提高他们为护理做出贡献的能力。旨在提高 RN 和 CNA 为疗养院居民提供高质量、全面护理的程度的举措对于居民的健康和解决护理短缺的问题至关重要。培训 CNA 并更改认证以使他们能够提供药物以解决未满足的临床需求并最大限度地提高他们为护理做出贡献的能力。旨在提高 RN 和 CNA 为疗养院居民提供高质量、全面护理的程度的举措对于居民的健康和解决护理短缺的问题至关重要。

高级执业护士 (APN) 的范围也存在类似的问题。确保 APN 可以在其执照的全部范围内执业的政策对于确保居民获得最佳护理是必要的。此类政策可能会通过优化 APN 对老年人获得和护理质量的贡献来阻止疗养院中 APN 的短缺。加大努力克服特定州许可的限制，为推进和确保适当的实践范围提供了额外的优势。最初于 2000 年批准的护理执照契约是各州之间的一项协议，允许护士拥有一个执照，但能够在协议中的其他州执业。2020 年，APN 采用了类似的流程，称为 APRN 契约（访问 https://www.ncsbn.org/aprn-compact.htm）。APRN 契约允许 APRN 持有一个多州执照，并有权在其他契约州执业。所有州护理委员会都必须利用这两个契约，同时努力促进 APN 的实践范围，使包括疗养院在内的任何环境中的实践更具吸引力和成就感。

解决疗养院特有的护理短缺问题必须体现在政策、程序和实践方面的进步，以实现强有力的文化变革。专门从事老年病学和在疗养院和其他环境中与老年人一起工作的原因被广泛接受的年龄歧视所笼罩，影响老年人和可能选择照顾他们的护士的歧视。在过去的几十年里，护士领导者设计了不同的项目来吸引人们进入护理领域，并吸引护士进入老年病学领域。教学疗养院模式以宾夕法尼亚教学疗养院试点的形式回归（访问 https://www.jhf.org/whatwedo/whatwedo-2/projects-and-programs）。当地的其他努力包括护理学校在疗养院提供强大的临床轮换，以及为学生提供在长期护理机构工作的机会的计划。相反，一些长期护理公司提供奖学金，以吸引学生的经济支持、在疗养院的培训以及毕业后的就业或居住。所有此类计划都提供了一些好处并可能取得成功，

消除在护理和我们更广泛的社会中持续存在的年龄歧视并解决养老院护理短缺的问题需要广泛的文化变革，消除对在养老院工作的错误印象，并建立对今天变老的积极和现实的理解。年龄歧视与其他形式的歧视相交叉并助长了其他形式的歧视，包括种族主义和性别歧视以及健康主义和能力主义。消除所有形式的歧视与疗养院至关重要，因为疗养院拥有高度多样化的直接护理人员。创造包容性的工作和生活环境必须是所有人繁荣发展的重中之重，并在长期护理方面建立多样化的领导能力，以更好地为我们日益多样化的社区服务。

长期护理工作的许多优势——从工作保障到向我们护理的老年人学习——经常被考虑不周的年龄歧视神话所掩盖。考虑两个经常被认为是避免在疗养院工作的原因的神话。误区一：疗养院实践乏味且重复。真相？疗养院居民护理的复杂程度和稀有程度是无与伦比的。罕见的情况通常很常见。多发病无处不在。技术有限。疗养院护士必须依靠敏锐的观察力、不断学习的方向和强大的团队合作来确保最佳护理。误区二：照顾老人既可悲又无趣。真相？照顾 80 多岁、90 多岁及以上的人是令人振奋的、有教育意义的和有趣的。最后一点请相信我们——我们拥有令人震惊的 166 年的老年医学经验！老年人教会我们所有关于复原力的知识，以及如何在最糟糕的时期恢复、生存和茁壮成长。它们提醒我们，舞会、与某人一起吃饭、看电影或与朋友一起爱好是永恒的快乐。你可以在疗养院做所有这些事情——甚至更多，在疗养院里和在外面一样享受其中的乐趣。

今天的护理短缺对我们任何人来说都不是新闻，尤其是对我们这些从事老年病学和长期护理工作的人来说。我们都有投资解决护理短缺问题，让照顾老年人成为今天、明天和永远的护士选择。怀着让自己变老的普遍希望，我们必须为老龄化社会重新构想养老院和疗养院。我们自己的医疗保健取决于它。我们知道，各地的护士，尤其是我们长期护理的同事，都是真正的英雄，但没有英雄可以永远与逆境抗争。我们现在都必须采取行动，在地方和全国范围内进行必要的变革。我们的未来掌握在我们手中。

Donna M. Fick，博士，注册护士，FAAN，FGSA

编辑，老年护理杂志

宾夕法尼亚州立大学教授

宾夕法尼亚州帕克

Sarah H. Kagan，博士，注册护士，FAAN，FGSA

老年护理学教授

宾夕法尼亚大学

宾夕法尼亚州费城

Barbara Resnick，博士，CRNP，FAAN，FGSA

编辑，老年护理

马里兰大学教授

马里兰州巴尔的摩

Heather M. Young，博士，注册护士，FAAN，FGSA

编辑，老年护理研究

教授和名誉院长，大学

加利福尼亚戴维斯

加利福尼亚州戴维斯

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