Leading article/Uvodnik
The development of nursing with older people a 21st century leadership priority
Razvoj zdravstvene nege starejših, pomembne prioritete 21. stoletja
Debbie Tolson
Nurses are increasingly engaged in policy developments and influencing the health care development agenda in response to a variety of drivers for change. More than a decade ago the International Council of Nurses (ICN) launched a global vision for the 21st century (International Council of Nurses,
2010)	declaring that the mission of nurses 'is to lead our societies to better health' (p. 1). As Benton (2012) explains, to realize this vision nurses need to be actively involved in shaping health policy and to be responsive to evolving health challenges and changing needs. This aligns with the World Health Organisation strategic directions to strengthen nursing and midwifery services 2011-2015 (World Health Organisation,
2011).
Population ageing is a worldwide phenomenon; it is currently estimated that one in every nine people in the world is 60 years of age or older, rising to one in five people by 2050 (United Nations, 2007). To respond to this demographic transition the World Health Organisation (WHO) advocate four key national strategies:
1.	the prevention of chronic diseases common in older age;
2.	the strengthening of health and social care systems for older people;
3.	the promotion of enabling, age-friendly environments;
4.	the re-conceptualization of ageing itself (World Health Organisation, 2012).
As nursing constitutes the largest health care workforce in most countries it follows that nurses have a significant opportunity to influence public health and contribute to the realisation of the WHO later life strategy. Accordingly, Skela-Savič (2014) advocates the development of nursing aligned with population health needs. In particular, Skela-Savič (2014) highlights the urgent need for higher levels of nurse education in Slovenia which is required to equip registered nurses
to meet the challenge of an ageing population. This call is echoed by nurse leaders around the world who seek to reform and achieve improvements in the standards of care provided to older people.
To advance practice anywhere in the world nursing needs clarity and confidence to articulate its contribution to the health and well-being of older people and family caring. This requires a nursing workforce equipped with the specialist knowledge, skills and value base that enables expert nursing with and for older people. It also requires an empowered leadership with the capability and commitment to influence public health policy and to champion better services and equality in the care of older people.
The economics of ageing are complex and in broad terms with rapid population ageing some countries become rich before they age while smaller economies tend to age before they become rich (Bloom, et al., 2010). Although it would seem logical that the development of nursing older people would be in tune with demographic and economic changes the evolution of nursing with older people has been slow to emerge in many regions. Furthermore, there are numerous examples of impoverished care environments in high income countries which hinder nurses with the right skill sets to deliver high quality care because the care environments are under-resourced. Many commentators note that nurses who choose to work with older people are afforded low status and unfavourable working conditions and compare the professional stigma that they experience with the historic stigmatisation of old age.
In administrations where nursing is overshadowed by medicine a treatment paradigm dominates and this can serve to supress the advancement of alternative models of care and supress the development of skilled nursing with older people. A professional failure to delineate, describe and promote the contribution of nurses to the health and health care of older people obscures the value of and
Professor Debbie Tolson, PhD, MSc, BSc (Hons), RGN, FRCN, University West of Scotland, School of Health, Nursing and Midwifery, United Kingdom Correspondence e-mail/Kontaktni e-naslov: Debbie.Tolson@uws.ac.uk
Received/Prejeto: 15. 10. 2014 Accepted/Sprejeto: 10. 11. 2014
hinders the development off expert nursing. Paradoxically, even in countries where nursing has greater autonomy and opportunity to advance, the perceived need for registered nurses can quickly be eroded by a failure to evidence the benefits of skilled nursing, particularly within long term care, such as within nursing homes (Tolson, et al., 2011). As McCormack and Ford (1999) cautioned over a decade ago, this opens up the real possibility of substituting registered nurses with cheaper vocationally qualified support workers. This is particularly problematic given the complexity of nursing needs that are associated with longevity, such as those associated with frailty and comorbidities that typify today's generation of older people. Furthermore, this stance perpetuates a reluctance to invest in advanced education programmes to develop specialists and better prepare general adult nurses to meet the needs of older patients. There is, however, growing evidence that this is a false economy which jeopardises the quality of care and hinders practice development and service improvement. For example, in the UK, the Francis Inquiry (2013), which investigated major failings in a national health service hospital in England, drew into sharp focus how a lack of expert nurses and nurse leaders skilled in the care of older people results in poor standards of care, system failures and patient harm (Francis, 2013). On a more positive note, a USA review of studies investigating the contribution of advanced nurse practitioners within nursing homes concluded that employing highly skilled nurses was associated with a decrease in the hospitalisation rates of older nursing home residents with either a decrease or no change in mortality (Bakerjian, 2008). A recent survey of clinical mentors in Slovenia further endorses the perceived benefits of greater levels of gerontological knowledge and the importance of gerontological nurse education at the pre-registration and post registration levels (Hvalič Touzery, et al., 2013).
In many countries, the goal of developing and advancing skilled nursing practice with older people presents a formidable challenge. Debates concerning the specialist or non-specialist nature of nursing older people are often conflated with workforce and resource challenges rather than focussing on the complexity of practice knowledge and the skills that practitioners require to deliver nursing care that is safe, effective, age appropriate and compassionate. Kagan (2009) attempts to move our focus from debates about specialism towards the adoption of gerontological principles. For some, this suggestion offers a practical solution, while others consider it a compromise cautioning that we may pay a high price in terms of our practice leadership and the quality of future services provided for older people. Kelly and colleagues (2005) a Scottish study reports about used involvement research methods to inductively develop a description of gerontological nursing with experienced nurses. Their justification for this approach was the recognition that the quality of nursing care is intrinsically linked to the quality of
decision-making and judgements in practice, which are dependent upon practice expertise. Their findings endorse the need for practice informed by agreed principles, but their recommendations also encourage us to be more ambitious given the complexity of gerontological nursing which they defined as:
'^a person centred approach to promoting healthy ageing and the achievement of well-being, enabling the person and their carers to adapt to health and life changes and to face ongoing challenges.' (Kelly, et al., 2005).
A major step forward in the United Kingdom has been the recognition by the regulatory body the Nursing and Midwifery Council that nursing older people is a specialism which requires highly skilled nurses who can respond to the complexity of health and social care needs of older people (Nursing and Midwifery Council, 2009, p. 6).
It follows that careful planning is required for pre-registration and post registration curricula in terms of equipping nurses to work with an ageing population. Although contexts of care and curricula may differ between countries, there is consensus in the international literature about the scope of nursing with older people:
-	health promoting aspects that enable people to optimise health, well-being and independence in later life,
-	curative and rehabilitative dimensions that focus on functional or psychological recovery from illness or injury,
-	facilitating self-care and enabling effective management of long term conditions,
-	providing care for those who become frail or with limited and or declining self-care capacity,
-	palliative and end of life care (Tolson, et al., 2011a, pp. 3-4).
For nurses to become experts in working with older people they must draw on knowledge from applied gerontology, geriatric medicine and generic nursing skills alongside the knowledge of the older person, their family and life circumstances (Tolson, et al., 2011b).
The challenge for nurse leaders, including nurse educators, is to steer a transformative path to ensure a positive future for nursing older people. This will require policy influencing, investment in practitioner education and an interprofessional commitment to explore new models of care that put older people at the centre and reject ageist or outdated approaches.
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Cite as/Citirajte kot:
Tolson, D., 2014. The development of nursing with older people a 21st century leadership priority. Obzornik zdravstvene nege, 48(4), pp. 256-258. http://dx.doi.org/10.14528/snr.2014.48.4.32