According to the UN, “The International Day of Older Persons is an opportunity to highlight the important contributions that older people make to society and raise awareness of the opportunities and challenges of ageing in today’s world.”

Around the world there is an estimated 703 million persons aged 65 and over. The region of Eastern and SE Asia held the largest number of older persons (261 million) which was then followed by Europe and Northern America (200 million).

The coming 30 years will prove critical to all societies, as the number of older persons worldwide is projected to more than double, reaching more than 1.5 billion persons by 2050. All regions will see an increase in the size of the older population between 2019 and 2050. In Eastern and SE Asia, this means a growth from 261 million to an estimated 573 million persons by 2050. The fastest increase will be experienced in Northern African and Western Asia with a 226% increase of older persons from 29 million people to 96 million in the space of three decades. The theme for this year’s 30th anniversary observance is, “Pandemics: Do they change how we address age and Ageing”. One of 2020 objectives for the International Day of Older People is to “increase awareness and appreciation of the role of the health care workforce in maintaining and improving the health of older persons, with special attention to the nursing profession.”

Ami Hommel, Svensk sjuksköterskeförening

In light of this, we spoke with Professor. Ami Hommel, President of  Svensk sjuksköterskeförening / Swedish Society of Nursing) and Kristina Iritz Hedberg, Board Member at Riksföreningen för Sjuksköterskor inom Äldre-och Demensvård (the National Association of Nurses in Elderly and Dementia Care). SSF has been a QSNA supporter since its establishment in 2013, and provides a platform for Swedish registered nurses to work together on professional issues. Founded in 1910, the Society continues to provide a forum for clinical, educational, scientific and ethical discussion and decisions regarding nursing. Today, there are approximately 60 000 members.

Discussions touched upon the scope of impact professional nurses can make in society; the challenges that COVID-19 have brought to the Swedish healthcare system; and how the fluidity of today’s situation will allow future nurse leaders to create opportunities for the next generation of talent.

Question: Would you like to introduce yourselves?

Ami H: I have been a nurse since 1981, specializing in orthopedic care primarily for older patients with hip fractures. I went into research in 1998, was accepted as a doctoral student in 2002, and defended my thesis in 2007 – all with a focus on hip fracture patient care. I was then appointed as Associate Professor at Malmö University in 2012 and then Professor in 2019. I continue to work at Malmö University’s department of nursing today, working with patient safety, elderly care and orthopedic care with a very person-centered care focus. I also have the role as President of the Swedish Society of Nursing.

Kristina Iritz Hedberg, Riksföreningen för Sjuksköterskor inom Äldre-och Demensvård

Kristina IH: I have been a nurse since 1998 and specialized nurse since 2015. I am a Board Member and Editor-in-Chief of “Ä. Leg. Sjuksköterska,” working as a publisher in the health care section of Liber Publishing with course literature for nurses and doctors. I have an enormous interest in emergency care, as well as home and palliative care for older people. On the weekends, to ensure that I keep up with my Swedish nursing license, I work as a nurse at a care facility in Stockholm. I studied at the Red Cross University  in Stockholm and specialized in elderly care at Sophiahemmet. I have been the President of the National Association of Nurses in Elderly- and Dementia Care in the past, and continue to contribute on its Board. 

Question: Both of you juggle a lot of different roles with nursing as the foundation. Could you speak about your respective scope of engagement with the nursing profession in Sweden.

Ami H: Since 1998 I’ve been dedicated to the research of hip fractures in older adults. This focus is naturally connected to patient safety and care. You have to talk to a lot of people – specialists, families, students, doctors, politicians – to get a balanced view on what it means to provide and receive safe care.  In order to fully appreciate the full picture of how we could address the safety and care for this group of patients. I need to gather the thoughts and experiences from as many relevant parties as possible. This also helps me with every other commitment I make as a nurse. I can be a better researcher, a better professor, a better President at the Swedish Society of Nursing. Having a huge network is not a burden. It is a joy and necessity when addressing healthcare challenges of any kind.

Kristina IH: I agree. You benefit from a large degree of synergy and when there are large networks to draw information and energy from. In Swedish we say that there is a “red thread” that binds all of these connections together. I know that the different roles that are available for me and all nurses today only strengthen our skills and abilities. If we are open to new experiences, people, and experts – then we have a better chance to gain a strategic overview of challenges. You need to have the ability to communicate with anyone from families to students to  the National Board of Health and Welfare. This gives nurses enormous leverage to inspire and inform others of the nursing experience and profession. You have the privilege of getting up close to the issues personally and professionally, and these networks are critical in creating positive change.

Question: Tell us a little about elderly care in Sweden in light of the current COVID-19 pandemic and what your organizations have taken from the experience so far. 

Ami H: It is clear that healthcare systems here in Sweden and around the world require more specialized nurses within elderly care. We really require these experts who have the knowledge and experience in older patient care to work with care teams and patients alike. I am based in Skåne which is the southernmost province in Sweden. We have seen that there have been three facilities where the death rates for the elderly have been particularly high; and other care homes where there have been no patient deaths at all. The common element in the latter cases is that there has been a specialized elderly care nurse who has organized and guided the process for safe and secure patient care and teamwork. We have found that in those instances where competence is on site, things work. This needs to be really highlighted since media outlets are not focusing on these positive stories where nurses are making positive impact.

In those environments where a specialized elderly care nurse’s expertise and abilities are drawn upon, the teams have not experienced a lack of equipment. These nurses were able to very quickly assess the risks, and make recommendations to act – such as closing facilities. Even now, as we cautiously open up again, nurses are able to contribute with creative ideas that allow for safe visits, such as the outdoor plexiglass barrier between visitors and residents. Having nurses on-staff means that there is a quicker understanding of potential safety breaches, and how to reduce hazards for both care teams and patients alike.

That said, at the policy level, we can do a lot to improve how Sweden operates elderly care environments. In 1992, the government issued the Elderly Reform Act. This allowed the 290 municipalities in the country to create their own guidelines and regulations for elderly care. Essentially this means that there are 290 ways in which elderly care can be operated our country.

If you place on top of this decentralization the fact that Municipalities have been in a cost-saving mode for a long time, then very difficult and risky circumstances arise. There is a lack of educated, skilled people within the care facilities. There never seems to be enough work for personnel to have full-time work in one elderly home, and thus s/he is forced to juggle work with multiple locations. A lack of stability, a lack of knowledge, and multiple rules have resulted in a dangerous situation allowed COVID-19 to take advantage of.

Kristina IH: I’d like to add that in 1992, Swedish municipalities created two layers within elderly care – i.e. health and social care. These should technically be on par with each other as they are both of equal importance. However, in light of the previous 1992 decision to decentralize elderly care to the municipality level, an obvious discrepancy has resulted between health and social care. Social care has received more attention over the years. While this has been valuable and very important in how we respond to cases, health and medical care has not been elevated at nearly the same level. Now we are seeing the results of that lack of health and medical competence development.

Swedish healthcare developments have allowed an older population to really thrive in recent times, with one of the highest life expectancies in the world. This also comes with chronic health issues as the older we get, our bodies will experience challenges. Swedes are living longer, but with more complex health problems. If you take a higher life expectancy, then you will require more expertise to address multiple chronic issues. Again a lack of knowledge in health and medical care will be seen here. Our elderly care competency development has not kept on par with our aging population. The Swedish Society of Nursing as well as the National Association of Nurses in Elderly and Dementia Care have flagged this widening gap of growing numbers of older people and diminishing elderly healthcare expertise for over 10 years.

You can see this at the most operational levels of care facilities today. In the past, there was a specialized elderly care nurse who can dedicated to the home full-time. Now this expert resource is on site for only a few days a week, or available via telephone. That knowledge source is being pulled away more and more because there simply isn’t enough competence to cover all the needs and this is not being invested in by Swedish policy makers.

Social care, might I add, is excellent in Sweden. But it isn’t skilled medical knowledge. Social care is all about providing reading circles, bingo, trips and excursions, and experiences that our older population richly deserve. However, this is meaningless unless this segment of society can actually enjoy these benefits to the fullest. Social care is not health care. If someone has chronic pain, how should health professionals provide relief? If older people are unable to stimulate their appetite, what energy will they have to participate in social activities? Social care is rich and multifaceted in Sweden, but we must have it balanced by skilled, educated healthcare knowledge.

Question: What direction would you like to see Swedish nursing take in the future of elderly care?

Kristina IH: Working as a nurse needs to revert back to actual patient care. Talented people with a lot of passion for people-centered engagement go into nursing because they get to work on a human scale. This is what has driven the nursing profession over the years.

We really need to think carefully about the message we are sending to the next generation of nurses. There are increasing numbers of vulnerable elderly around the world who require our help, but the money, training and time that is being invested in this area is dwindling.  There are challenges ranging from language to safety to wages to lack of benefits to guidelines to funding structures to learning opportunities to advocacy.

In Sweden, we have municipality-steered elderly care systems. There is nothing at the national healthcare level that guides the development of the 290 structures that Ami mentioned earlier. If there is a lack of guidance that ties these systems together, then it makes it very difficult to know what you are able to do or not do. Are you allowed to insert an IV? What happens after 16.00 or 17.00 when there is no nurse available immidiatly at the place after those hours?  How long should an elderly patient wait for medical help? The lack of direction, training, and security in work makes this a very delicate balance that is vulnerable to risk.

What we believe Sweden requires is actual investment in administration and guidelines that clearly state the baseline of equipment in facilities, lines of responsibility, communication processes, competency level amongst many other things. There is a lot to be done! If we come out of this pandemic without actual investment in administrative structures and regulations, then no real change can be realized in this critical area of care. At the very highest levels, we need leadership that has the strength, vision and responsibility to put elderly care back into the right again.

Question: In term of the COVID-19 response, how has the Swedish Society of Nursing advocated for your 60000 members

Kristina IH: Already in December last year, we held meetings with several stakeholders such as Swedish municipalities and county councils, representatives from universities, and operational managers within elderly care.  We raised our concerns about our national response systems being ill-prepared for the arrival of COVID19. We expressed our deepest concerns that the burden of care would lay fully on Swedish nurses.

We have long identified the challenges in patient care and patient safety due to the structure, financial and administrative changes which left both professional care teams and patients in exposed circumstances. What we are seeing and experiencing has been 20 years in the making. Changes have chipped away at how we respond and address elderly care. What COVID-19 did was expose these weaknesses in a very obvious way.

We will need to gather around to get on the same page to make changes so that this never happens again. We need to collaborate at the broadest levels to make this happen.

Ami H: if we want our nurses to be able to achieve higher levels of competency and knowledge, especially to address the fast-growing elderly populations, then we need to be providing continuing education opportunities that are worth their while to invest in.

At this time, a specialist nursing education here in Sweden results in a loss of time and sometimes even wages. We know of colleagues who have invested their money, time, and efforts into specialist nursing education; and were offered 5000 SEK less per month because they were only “entry level specialists.” This is sending a very discouraging message to our nurses and must be addressed by stakeholders including our unions.

Question: we understand that this year’s applications for nursing education at the university level has increased by 34%. Any reaction to this increase in nursing interest?

Ami H: Yes – it is certainly very positive to see that more people are interested in the nursing profession. We need to be aware however, that with more people requesting this skill that we will need more skilled professionals to guide them through this journey. We need studies to be of high quality and sustainable for both instructors and students alike. This means that more investment needs to be made to ensure that lecturers are on hand with the right knowledge and skills to mentor and instruct the next generation of talent. We also need to ensure that the talent is entering with the right competency, mindset, and potential. We want to see them successful learn, grow, graduate and contribute. The entry point for a Swedish nursing education should not be compromised to fill spots. We need students who have the metal to enter the training and to ultimately complete it to practice effectively in the Swedish healthcare system.

Question: What opportunities do you see for the next generation of nursing leaders? What kind of people are needed and what is your advice to nurses who want to make a difference?

Kristina IH: I encourage the next generation of nurses to be proud of your knowledge and skills, and invest the time to go through the terminology, philosophy, research theories and science of nursing. This is a deeply complex, fascinating and exciting field and your pride in this helps elevate our profession.

Ami H: If we take with Kristina IH said and add that publications also need to also sit up and take notice. The nursing experience has not particularly raised much interest in medical journals, and this is not the right message we want to send to future nursing talent. Our experiences and expertise matter. If we have a pride in our profession from care and medicine, then we will be on par with all medical professionals worldwide.

Kristina IH: I’d also like to encourage tomorrow’s nursing talent to rethink leadership in healthcare environments. Quality does not denote quantity. Nurses and other medical professionals are trained in person-centered care, but healthcare leadership is moving far from this patient focus. If you look at the typical hospital today, it is headed by an operations manager who was trained as a finance director. This is counter to how medical personnel is trained. We need to have doctors, nurses and rehabilitation specialists back in positions of leadership in these care environments. These are the professions where you have a premium on competence in medicine, patient safety as well as ethics and integrity of the people in question.

Healthcare is not a spreadsheet with processes, flow charts, and balance statements. It remains a human-to-human interaction that is driven by our mutual ambition to help each other. And we need to recapture that essence for the future of our healthcare systems.

Sources, and for read more:

By UN – International Day Of Older Persons

By UN – Older Persons Day

By UN – International Day of Older Persons – 2020unidop

By SweNurse – About the Swedish Society of Nursing