Chapter 9 excerpted from "The Economic Power of Care: Our Nurses. Our Future" published by the International Council of Nurses.  

By Joanne Spetz, Roy A. Thompson, and Laura M. Wagner

Rapid population ageing is exerting significant pressure on long-term care (LTC) systems worldwide. As life expectancy increases and birth rates decline, more of the global population is entering their senior years (WHO, 2015). It was estimated that 142 million older people required assistance to meet their basic needs in 2022 (WHO, 2022f) and the number in need of support is projected to increase by 100 million between 2015 and 2030 (ILO, 2019). There will be variation in the rate of growth across nations, and countries that are experiencing greater improvements in life expectancy will also face the most rapid increase in their older population, including China (OECD, 2023a) and nations in Latin America and the Caribbean (PAHO, 2019). While family, neighbours and friends provide support to older people worldwide, population ageing is generating a rising demand for quality LTC services. This increasing demand will strain health care systems globally, challenge health care budgets, and necessitate the recruitment and training of more health care professionals to meet the unique needs of older adults.

Nurses are indispensable and vital to LTC systems. LTC nurses provide essential nursing care, emotional support and advocacy for residents or patients with complex health challenges. Their compassionate approach is instrumental in improving the well-being and dignity of those in LTC.

Innovative nursing models that encourage leadership and collaboration contribute to better health outcomes. Nurse-led interventions in LTC facilities can improve management of conditions like diabetes and dementia, which improve residents’ quality of life and cut costs for the facility. Nurse-led care programmes and interventions have positive economic and clinical benefits, largely through avoiding hospitalization costs (Grabowski, O’Malley & Barhydt, l., 2007). One study of a nurse-led intervention, INTERCARE, reduced hospitalizations and improved care outcomes of nursing home residents in Switzerland (Bartakova et al., 2022) by training nurse leaders who implemented the programme; these quality improvements generated positive economic returns to the health system as a whole. Furthermore, enhancing the training of registered nurses and assistants in nursing care facilities can generate economic benefits. One training programme in New York that focused on fall reduction risks reported significant decreases in falls alongside net cost savings(Teresi et al., 2013).

It is crucial to have adequate numbers of registered nurses in LTC. Numerous studies have documented that better nurse staffing in LTC impact patient outcomes, which ultimately results in cost savings to care for residents. Greater staff hours per resident day are associated with better care quality for registered nurses and nursing assistants internationally, including in Canada (Boscart et al., 2018), South Korea (Shin and Hyun, 2015), China (Kwong et al., 2009) and the United States (Shin & Bae, 2012). Better staffing in LTC facilities leads to fewer falls, decreased aggression and less deterioration of range of motion among residents. Increased registered nurse staffing confers benefits to residents, including lower rates of pressure injuries, infections and pain (Jutkowitz et al., 2023, Perruchoud et al., 2021). Staffing instability, on the other hand, contributes to higher rates of emergency department visits, worsening mobility among residents and increased support required with activities of daily living (Mukamel et al., 2023). The cost savings associated with improving resident outcomes are significant; an economic analysis that focused on the costs of pressure injury treatment, hospitalizations and urinary tract infections found that more registered nurse time per resident day led to a net financial benefit for society (Horn, 2008, Dorr et al., 2005). By optimizing nurse staffing and knowledge in LTC, facilities can achieve cost-efficiency while providing higher-quality care, benefiting both patients and health care systems.

Nurses help improve health and reduce costs by caring for older adults in communities instead of transferring them to LTC facilities and hospitals (Tappenden et al., 2012). Nurses in the Buurtzorg “neighbourhood care” programme in the Netherlands cost more per hour than traditional care approaches, yet analyses show that fewer hours are needed with these expert nurses, thus saving money. Older adults served in this model, which has now been adapted globally, are highly satisfied and less likely to use emergency hospital services. Similarly, nurses working in the United States-based CAPABLE programme develop person-centred interventions to keep patients at home through goals around pain, medication, depression, and physical function, leading to financial savings from reductions in hospital and nursing home admissions (Szanton et al., 2021).

Direct investment in LTC nursing staff through higher wages is associated with better care quality and paradoxically generates an economic benefit. Research reports a positive association between higher hourly wage of assistive staff and nursing home quality ratings (Allan & Vadean, 2023), and lower nursing assistant turnover (Sharma & Xu, 2022). Policies that support higher wages for staff, like minimum wages, are associated with greater nursing assistant hours per resident day, likely due to the wage growth pulling more people into long-term care jobs (Sharma & Xu, 2022). Cost-effectiveness analysis indicates that longer average registered nurse tenure in nursing homes results in lower net expenditures when considering cost savings from lower rates of hospitalizations and deaths (Uchida-Nakakoji et al., 2016).

Many sub-Saharan African nations are experiencing faster growth of their older populations than the global average growth rate and, although some community and residential care models are emerging, services are limited (WHO, 2017b). Investment in workforce development, including nurses and assistive staff, is needed to support families facing financial burdens to care for older adults (Essuman et al., 2018).

Investing in nursing is not only good for the dignity of the profession, but also a sound economic decision. Nurses are essential caregivers and key players in the financial sustainability and efficiency of health care systems worldwide. These investments are essential because they:

• Increase nurses’ knowledge of gerontology and LTC. Nurse training in the development and implementation of interventions that support optimal health for older adults benefit the people served and the health system that reaps lower downstream costs. Governments and health care systems should enhance funding for gerontological nursing education.
• Improve nurse staffing in LTC. Extensive research shows the importance of adequate, stable employment of registered nurses and assistants and optimal nurse-to-patient ratios. This will improve the quality of care and increase economic savings by reducing adverse events, hospital readmissions, lengths of stay, and dignity of LTC facility residents (Oosterveld-Vlug et al., 2013).
• Support nursing leadership and research. Investment in nursing leadership development programmes can empower nurses to lead changes in practice that improve LTC quality, and support the development of innovative, cost-effective, patient-centred care models.
• Increase nurse wages in LTC. Globally, nurses who work in LTC are paid lower wages than those who work in hospitals. This is detrimental to both nurses and LTC patients, and results in higher costs to address rampant turnover and lapses in the quality of care.
• Develop and expand nurse-led interdisciplinary care models. Encouraging interdisciplinary collaboration with nurses enhances care coordination, improves patient outcomes, and prevents unnecessary expenditures associated with fragmented care.

To ensure the sustainability and efficiency of LTC systems, it is imperative that policymakers, health care administrators, and stakeholders consider the far-reaching implications of nursing investments. These investments will pave the way for a future where high-quality LTC is inextricably linked to economic gain and will secure a better health outlook for the aging population.