Looking back at 30 years of older people’s nursing
Older people’s nurses remember three decades of challenges and developments in the specialty
Older people’s nurses remember three decades of challenges and developments in the specialty
For the 30th anniversary of Nursing Older People in June 2019, I asked older people’s nurses to look back over the past 30 years to identify the highlights, challenges and developments in the specialty.
An important question was whether they thought older people’s nursing is in a better place today than it was 30 years ago.
In June 1989, when this journal was reborn as Nursing the Elderly (see cover below) from Geriatric Nursing and Home Care, it was arguably at the cutting edge of updating the specialty’s image, although some areas of practice were perceived to be lagging behind.
RCN professional lead for care of older people and dementia Dawne Garrett recalls: ‘In the late 1980s I witnessed practice I find hard to believe now: an elderly care unit where each morning patients were sat on the lavatories in cubicles that had no doors and were fed porridge. The unit prided itself on the fact that, because of this, they never had to use aperients.’
‘No golden age’
‘It taught me a lot: how human rights are eroded by systems, how audits can be flawed, how we become used to something and stop questioning. It taught me there is always another way – and there was no golden age.’
Dementia UK professional and practice development lead for Admiral Nursing Rachel Thompson, who also qualified in the late 1980s, says: ‘At that time we had long-stay geriatric wards, often Nightingale style – one large ward without subdivisions and with 20 or more beds – with routine-based care, little privacy and where people were admitted with little expectation of recovery or discharge.’
Independent nurse consultant Abi Masterson, who was proud to be a subscriber to the journal in the 1980s, comments: ‘Against the dominant mores of the time and the warnings of my tutors, I wanted to go straight into care of the elderly as it tended to be called by the more enlightened, or geriatrics by the less enlightened.
‘Reading a journal and being interested in research and best practice was fundamental to my education, and subscribing to a particular journal was important in my conception of elderly care nursing as a specialty.’
Appalled by age discrimination
Abi was appalled by age discrimination in health services, and she discovered that in the hospital where she worked ‘if you were admitted to a geriatric ward, you were automatically deemed DNR (do not resuscitate) regardless of your own wishes or diagnosis’.
So much for rose-tinted spectacles. The late 1980s and 1990s could be tough for older people and their nurses.
Over the subsequent years there has been a shift towards identification and management of frailty, which includes a significant change in services for people with dementia. Rachel Thompson recalls that 30 years ago: ‘People usually received a diagnosis fairly late in the condition, were described as “demented” with little expectation that anything could be done to help, and only received specialist support if they had “mental health problems” as a result of their dementia.’
The publication in 2009 of a national dementia strategy for England, called Living Well With Dementia, was the first recognition of the need for focused expertise in this area of practice, predominantly with older people.
Older people with frailty
Since then all the UK countries have published one or more action plans or strategies to improve care for people with dementia.
Independent nurse consultant Gwyn Grout says: ‘It is interesting to reflect how the current focus on older people with frailty, and the attention given to the devastating condition of delirium, are now showing that working with older adults requires a highly talented, multiprofessional workforce who are proud to be working in the specialism – rather than being asked whether they couldn’t find a better job.’
The Human Rights Act 1998 and country-specific legislation in the UK relating to mental capacity led services to scrutinise older people’s rights, choice, consent and representation. Policies such as the National Service Framework for Older People (NSF) 2001 and the Commission on Dignity in Care 2012 triggered the redefinition of concepts such as person-centred and dignified care.
Jonathan Webster, interim regional chief nurse, NHS England and NHS Improvement (South East Region), comments that the NSF ‘shone a light on older people's care and provided a framework to help support practice and service transformation at an organisation and system level’.
Change in choices for patients and residents
The place of care for older people also underwent a seismic shift with the implementation of the NHS and Community Care Act 1990, the first major reform of the NHS since it was founded in 1948.
Gwyn Grout recalls: ‘When I was promoted to lead a team working on a long-stay psychogeriatric ward in a large out-of-town institution, such wards were backwaters and not the best advertisements for person-centred, recovery-focused practice. Opportunities to re-examine the service provision for older people with mental health needs exploded with the closure of the big institutions.’
Royal Hospital Chelsea director of health and well-being Deborah Sturdy agrees. ‘The change in choices for patients and residents has been enormous. Service development, community-based services negating the need for hospital discharge and expediting discharge from acute care have provided new roles for nurses, but importantly better outcomes for older people.’
Intermediate care policy and services
Awareness of evidence-based practice and clinical audit led older people’s nurses to review practices and innovate. In 1989, King’s College London professor of healthcare for older adults Ruth Harris was a primary nurse in the Byron Nursing Development Unit (NDU), one of four such units funded by the King’s Fund charity that year.
She was subsequently the sister/senior primary nurse when Byron became a nursing-led inpatient unit providing inpatient beds for people who primarily needed nursing care. She says: ‘Research undertaken on the unit demonstrated that nurses could substitute for doctors with patients whose acute medical needs were resolving and who required inpatient intermediate care. This work was at the forefront of the development of intermediate care policy and services.’
Dawne Garrett agrees: ‘The heady days of NDUs were the inspiration for me to set up two practice development units. The timely introduction of advanced roles and the opportunity to have been one of the early advanced practitioners and nurse consultants pushed at boundaries.’
At the forefront of care transformation
Over the past 20 years, careers in older people’s nursing have started to flourish. In 1999 Rachel Thompson realised her ‘dream job’ as an Admiral Nurse, at that time the only recognised dementia specialist nurse role.
Jonathan Webster was a second-wave nurse consultant for older people from 2001-09. ‘Over that time I saw the positive focus on nursing older people grow and develop,’ he says. ‘Nurses and clinical professionals were leading programmes of work that transformed care and service delivery, which in turn led to better person-centred outcomes.’
Post-registration education moved on from the English National Board (ENB) courses to master’s level programmes, including Health Education England’s Older Persons Fellowship at King’s College London, for which I am the clinical lead.
I have to confess to a nostalgic pang when I visited the RCN’s Aspects of Age exhibition and spotted the brochure for the ENB 941 care of the elderly course (the exhibition is on until 30 September in the Library and Heritage Centre at the RCN’s London headquarters.)
The RCN’s work on older people’s issues over the past three decades has been a consistent support for nurses across the UK who have struggled against age discrimination and low staffing levels.
Focus on expert nursing
Mr Webster recalls that the college’s Gerontological Nursing Programme in the 1990s ‘provided a focus on expert nursing in the care of older people and leadership in developing person-centred ways of working underpinned by practice development’.
More recently, the Safe Staffing for Older People’s Wards publication in 2012 highlighted the extent to which older people’s services were disadvantaged in terms of skill mix and launched a call to action.
The RCN remains in the vanguard of modernising the image and practice of older people’s care. The British Geriatrics Society, despite its retention of the ‘G’ word, is also emerging as a significant interprofessional forum for nurses, doctors and allied health professionals working with older people.
What of the future? Dawne Garrett says: ‘I see the development of extraordinary future nurses and, most importantly, a passion for the values of good healthcare. I am proud we are the most trusted profession.’
Strive for improvements
For Rachel Thompson dementia must remain a focus: ‘We still have much to do, including improvements in post-diagnostic support for people with dementia and their family carers, equal access to care and more research. Nursing has a significant contribution to make in delivering positive, relationship-centred, dementia care – I hope that we continue to strive for improvements.’
Deborah Sturdy urges older people’s nurses not to be complacent: ‘We have fought long and hard for recognition of the extraordinary skill, complexity and coordination that make older people’s nurses important clinical leaders in today’s health and social care system.
‘It was a 30-year battle worth fighting, as it has delivered better outcomes, experience and service as a result. We should not be complacent but use this foundation to continue to build an even better future.’
Nicky Hayes is consultant editor of Nursing Older People, and nurse consultant for older people, King’s College Hospital NHS Foundation Trust, London
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