Elsevier

Mayo Clinic Proceedings

Volume 78, Issue 8, August 2003, Pages 1026-1040
Mayo Clinic Proceedings

Symposium on Geriatrics
Caregiver and Clinician Shortages in an Aging Nation

https://doi.org/10.4065/78.8.1026Get rights and content

Despite a burgeoning elderly population, the number of nurses and other providers of direct care has declined to critical levels at many health care facilities. There are also insufficient medical clinicians to meet the demand for health services. A shrinking workforce, an aging population, financial pressures, and increased consumer demand will translate into severe personnel deficits in the future. Similarly, family fragmentation and the trend toward bureaucratization of long-term care have reduced the availability of informal caregivers. Younger workers should be considered a scarce resource for health care organization and planning purposes. The ability of the United States to meet its entitlement promises is likely to be compromised by a reduced labor pool and simultaneous budgetary constraints. Because good geriatric care is often labor-intensive, meeting this goal poses an increasing challenge.

Section snippets

THE DIRECT CAREGIVER: WHO AND AT WHAT COST?

“Who is going to take care of the elderly population?” is a key question in any discussion about the aging of America. Professional health care staffing has already reached crisis proportions across the United States.1 At the same time, family members are experiencing greater difficulty meeting the care needs of aging relatives.2 The caregiver role will be in increasing demand as the frail, elderly population expands. The caregiver role can include assistance with higher level (“instrumental”)

FEWER AVAILABLE WORKERS

A recent International Commission on Global Aging declared, “The major social crises of the twenty-first century will be the byproduct of labor shortages.”5 As the post– World War II US baby boomers age and require assistance, the “baby bust” generation will be relied on to provide direct care services for this elderly cohort. By 2030, the number of people older than 65 years will have grown to 70 million (a 125% increase from 1990), including a doubling of those aged 85 years and older (to 8.9

Nurses

In the past, nurses provided the bulk of formal or paid nursing services. Now, registered nurses (RNs), licensed practical nurses (LPNs), nurse aides, home care aides, and personal care assistants are among the nursing care providers available to the elderly population. Nursing care for elderly persons is provided across the health care continuum, from hospitals and acute care clinics to private homes, hospices, and long-term care settings. The precise job descriptions and titles may differ

Description

Total staff employment among 17,000 US nursing homes is approximately 1.4 million, of whom 617,000 (44%) are nursing assistants. These unlicensed nursing providers are not required to have a high school diploma, but federal law requires that caregivers in Medicare-certified and Medicaid-certified nursing homes complete at least 75 hours of training and pass a competency evaluation within 4 months of employment (becoming certified nurse assistants [CNAs]). Also, CNAs work in hospitals, assisted

INFORMAL CARE PROVIDERS

Most care provided to functionally impaired elderly adults is not technology-intensive and is performed informally (outside of the job market). The typical caregiver is a female family member, married, and in her mid-40s, and she works full time. She spends on average 11 hours per week providing care, although 36% spend 21 hours per week or more in these activities.57 The burden of elder care for families has demonstrably worsened since 1990, not unlike that experienced by the nursing

Physicians

The older adult patient has unique characteristics that demand differentiation from the usual care of nonelderly adults. Care of the aged population requires knowledge of the atypical presentation of disease, frailty, multiple comorbidities, chronic diseases, and inappropriate medication use, combined with an awareness of social needs and threats to physical function. Geriatricians focus on maintaining or improving function and endeavor to avoid iatrogenic impairments. These goals can be

DISCUSSION

The number of hands-on caregivers and nurses has diminished considerably in recent years, approaching critical levels in certain domains. This can be traced to the relative decline in the working-age population and the availability of other job opportunities. As a result, a lack of sufficient direct care workers will remain for decades, leading to staffing shortages affecting private homes, nursing homes, home health care, and hospitals. For similar reasons, employees who support their aging

REFERENCES (126)

  • HR Kelman et al.

    Longitudinal patterns of formal and informal social support in an urban elderly population

    Soc Sci Med

    (1994)
  • JM Mellor

    Long-term care and nursing home coverage: are adult children substitutes for insurance policies?

    J Health Econ

    (2001)
  • PI Buerhaus et al.

    Implications of an aging registered nurse workforce

    JAMA

    (2000)
  • C Levine

    Rough Crossings: Family Caregivers' Odysseys Through the Health Care System

    (1998)
  • JP Sloan

    Protocols in Primary Care Geriatrics

    (1997)
  • J McNeil et al.

    Americans With Disabilities 1997: Household Economic Studies

  • W Mondale et al.

    Summary Report of the Co-chairmen and Findings and Recommendations of the CSIS Commission on Global Aging

    (August 29, 2001)
  • US Census Bureau

    Profile of General Demographic Characteristics 2000

  • US Census Bureau

    (NP-T3) Projections of the total resident population by 5-year age groups, and sex with special age categories: middle series, 1999 to 2100

  • KG Manton et al.

    Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999

    Proc Natl Acad Sci U S A

    (2001)
  • RH Binstock

    Older persons and health care costs

  • RH Binstock et al.

    Issues affecting the future of long-term care

  • G Cunningham et al.

    Final report of the Citizens League Committee on the Labor Shortage in the Twin Cities

    (November, 1998)
  • BW Frank et al.
  • R Husbands

    Consultative and collaborative organizations which deal with selected fields of labour administration

  • P Zurn et al.

    Imbalances in the Health Workforce: Briefing Paper

    (March 2002)
  • Southeast Asia

    Migration News

    (August 2002)
  • American Red Cross. Armed conflicts abroad dominate the 1940s and 1950s

  • MC Harrell et al.
  • VT Grando

    Making do with fewer nurses in the United States, 1945-1965

    Image J Nurs Sch

    (1998)
  • S Tabone

    Thoughts on nurse shortages

    Tex Nurs

    (October 1999)
  • Division of Health Care Services et al.
  • Foreign nurses and the shortage

    Healthscope International

  • The Registered Nurse Population: National Sample Survey of Registered Nurses-March 2000

    (February 2001)
  • US Department of Labor et al.

    Occupational Outlook Handbook: Registered Nurses

  • CH Ellenbecker et al.

    The nurse shortage: a home care agency perspective

    Caring Magazine

    (July 2001)
  • US General Accounting Office

    Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors

  • SREB Fact Book on Higher Education. Table 32: Nursing school enrollment

  • American Association of Colleges of Nursing

    Faculty shortages intensify nation's nursing deficit

  • TM Valiga

    The nursing faculty shortage: National League for Nursing Perspective. Presented to: National Advisory Council on Nurse Education and Practice

  • R Steinbrook

    Nursing in the crossfire

    N Engl J Med

    (2002)
  • J Heinrich et al.

    Testimony before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives

    (August 1, 2001)
  • J Sochalski

    Nursing shortage redux: turning the corner on an enduring problem

    Health Aff (Millwood)

    (September-October 2002)
  • Health Resources and Services Administration

    Health workforce analysis: projected supply, demand, and shortages of registered nurses: 2000-2020

  • US Census Bureau

    DP-1: Profiles of general demographic characteristics: United States: 2000

  • Health Resources and Services Administration

    Projected supply, demand, and shortages of registered nurses: 2000-2020. July 2002:3

  • SR Gregory

    The nursing home workforce: certified nurse assistants

    (July 2001)
  • Paraprofessional Healthcare Institute
  • C Harrington

    Testimony before the United States Senate Committee on Aging

    Nursing Home Residents: Short-Changed by Staff Shortages

    (November 3, 1999)
  • TG Thompson
  • JG Brown
  • Wilner MA, Wyatt A. Paraprofessionals on the front lines: improving their jobs improving the quality of long-term care....
  • Y Yamada

    Profile of home care aides, nursing home aides, and hospital aides: historical changes and data recommendations

    Gerontologist

    (2002)
  • US Dept of Labor et al.

    Occupational Outlook HandBook

  • JA Giacalone
  • US Dept of Labor et al.

    Occupational Outlook Handbook: Nursing, Psychiatric, and Home Health Aides

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