Reflecting on our perceptions of the worth, status and rewards of working in nursing homes

Concerns over standards of medical care in nursing homes have a long pedigree. In an account published in 1797, Sir Frederick Morton Eden noted that when Oxford’s Board of Guardians inspected the workhouse, they criticised it heavily ‘as the very reverse of what they conceived a house of industry ought to be… no regular wards appropriated to the sick aged or infirme [1]’. Equally, it was noted in 1794 that ‘the conduct of work-houses in general, those receptacles of the old and the infirm, of widows and orphans; which, though capable under proper management of answering many excellent ends, too often become scenes of misery to the aged’ [2].

While the intervening centuries have brought a modicum of improvement, usually after crises or scandals, such as occurred in the USA [3] and Ireland [4], it is fair to say that the quality of healthcare provision in nursing homes across the globe is not routinely congruent with the complexity of care needs of residents or the advances of modern geriatric medicine and gerontological nursing. Even within these disciplines, the degree of research and reflection has been modest and relatively recent [5], perhaps indicating the challenge of prioritising the many diverse health needs of an ageing population across the spectrum of health services, or possibly a professional echo of the low political salience of quality of care in nursing homes.

Regulation and routine measurement of quality measures such as those provided by the internationally validated interRAI [6] are important developments but are not sufficient to assure quality of care or professional engagement in nursing home care [7]. While geriatricians have made efforts to promote higher standards through their professional bodies, as exemplified by the leadership of the British Geriatrics Society in the United Kingdom [8] or the European Union Geriatric Medicine Society [9], it has been increasingly clear that improvement in medical care requires a broader palette of action and strategic efforts to influence official and public perception of meeting care needs in nursing homes.

One strategic point of engagement is to provide more focussed and realistic advice to those commissioning medical care in nursing homes, as described by one of the most dynamic group of researchers on nursing home care in the United Kingdom in this issue (ref). The key strength of the approach used by the authors is their inclusion of the broad range of stakeholders involved in service delivery within nursing homes, including residents, relatives, care home staff, community nurses, allied health professionals and general practitioners.

What is notable about their findings is the degree to which they provide a template for a broader action on developing better care, in particular the task of generating a focus that legitimises and values work with nursing homes and the emphasis on relational working between practitioners. Up to now, initiatives in quality improvement have largely been developed within individual professional organisations. In a world where gerontological expertise remains scarce, it is vital that there is more joined-up thinking between the healthcare professions involved in nursing home care.

From the medical perspective, linkage between family doctors (who provide the majority of medical care in nursing homes across the globe (EUGMS survey, data on file)), geriatricians and old age psychiatrists must become a priority so as to provide guidance on core competencies and optimal liaison between these specialities and other health and social care professionals. The institution of a more formalised cadre of nursing home physicians has developed in the Netherlands, and to a lesser extent in the United States [10], but it is troubling to note the paucity of formal collaboration between the professional organisations of nursing home physicians and geriatricians in these countries.

A more telling absence in initiatives to date is that of gerontological nursing, a key stakeholder whose global development has been variable to the point that it is one of the few nursing specialisms that does not have a European professional organisation. It is striking that the literature on nursing in nursing homes frequently mentions the importance of developing expertise in palliative and dementia care, but rarely that of gerontology, a knowledge base which incorporates elements of all three competencies [11]. Gerontological nurses are best placed to promote the education and training of other staff, such as care assistants, that is critical to the development of person-centred care [12]. Nurturing, formalising and mainstreaming the contribution of gerontological nursing should be a central goal of future projects to improve healthcare in nursing homes.

There is also a need for the caring professions to use the principles outlined by the authors to further develop joint working with organisations representing older people, whose initiatives in quality of long-term care have generally been prepared without engagement with the geriatric medicine and gerontological nursing [13]. The exemplary lead by the British Geriatrics Society in its work with Age UK on frailty provides a potential template for joint action [14]. This not only engaged the national advocacy organisation for older people with a key concept of age-related disability but also reshaped terminology and responses to frailty for healthcare professionals in manner appropriate and acceptable to those who are most affected, older people.

For geriatricians, all such developments will also require a collective reflection on our perceptions of the worth, status and rewards of working in nursing homes as a core element of the portfolio of services needed by older people. The low profile of nursing home care in our literature and scientific conferences suggests that we harbour ambivalence about such engagement, and we need to more openly discuss how to support and structure this care within geriatric medicine and its increasing array of sub-specialisations in geriatric medicine. Given that this is a global issue, much can be learned also from an outward-looking perspective to learn from successful initiatives integrating hospital-based geriatrics with nursing home in other jurisdictions [15] or evolving international special interest groups, such as that for long-term and nursing home care in the European Union Geriatric Medicine Society http://www.eugms.org/research-cooperation/special-interest-groups/long-term-care.html. The history of the progress of geriatric medicine suggests that this combination of inward and outward reflection will synergise with the inherent cautious optimism and counter-cultural activism of the discipline to improve care in a service that a significant minority of us too will avail of in due course.

Key points

• Medical care in nursing homes does not routinely match developments in geriatric medicine and gerontological nursing.

• Improvement in medical care requires a broader palette of reflection, action and strategic advocacy.

• Nurturing, formalising and mainstreaming the contribution of gerontological nursing should be a central goal of future strategy.

• Geriatricians should reflect on our perceptions of the worth, status and rewards of working in nursing homes.

Conflict of interest

None.

Funding

None.