Achieving innovation requires knowing history

The study of the history of nursing is relatively spare; that of gerontological nursing thinner still. We live and practise gerontological nursing during an age where the desire for historical reference and comparison is inescapable. Current heightened interest in and the use of the history of public health and of health care draws the scant documentation of our history into sharp focus. Today, we frequently encounter references to the history of public health campaigns and even of hospitals in popular media. Some media allow us to marvel at oral histories obtained from people old enough to compare a past public health crisis to the present. Individuals whose lives span more than a century allow them to recall firsthand experience the 1918 influenza pandemic as they reflect on how they endured the COVID-19 pandemic, offering readers perspective and hope. Reading poignant reflections and compelling life stories of those who lived through the 1918 flu pandemic prompts me to ponder the relative paucity of documented histories in gerontological nursing. The histories of the nurses who care for older people, the older people who are not spectacular survivors but simply folks in need of nursing care and the places and spaces where those nurses and the older people in their care found themselves are more consequential today than ever before. But, finding those histories is challenging—books, articles and films documenting those stories are hard to locate. The notion that those who do not know, remember and learn from the past are destined or doomed, depending on the direness of the prediction, to repeat it appears in many aphorisms and quotes across centuries and cultures. Gerontological nursing appears destined and sometimes sorrowfully doomed to make this grand aphorism reality. Recognising the danger that lies in the reality of repeating the past in care for older people, my aim in writing here is twofold. I wish to call out scantily documented histories of our work caring with and for older people in all settings from home to hospice. Simultaneously, I intend to illustrate just how much we potentially and actually risk losing if our unknowing ahistorical stance persists. Two examples clearly illustrate our progress towards this unenviable destiny. First, we invest in recurrently assaying different groups of nursing students' attitudes towards older people. Gerontological nurses and nurse teachers around the world survey current students across levels of education for evidence of misinformation, misperception, resistance or even overt ageism. Such studies often rely on measures introduced in the middle of the twentieth century and commonly emerging from the United States. The measures are exported in these descriptive studies, unchanged across time and cultures. Sometimes, this research is introduced with a worthy claim of being first in the given culture. More frequently, the studies are more prosaic and simply seek to replicate what is already known in other societies in a new sociocultural context. With reviews of extant evidence assiduously conducted, the findings show corroborates extant knowledge of students' skewed attitudes and limited interest in care for the largest group of healthcare consumers in any society—older people. Our redundant replication of these studies reverberates with peril attendant in neglecting history with research in this phenomenon. Decrying limited interest in and recruitment to gerontological nursing and, more broadly, care for older people in situations not specified as specialist gerontological care is commonplace. The extent to which we examine attitudes and beliefs hoping for answers not possible to obtain in these descriptive studies calls to mind another pithy maxim involving repeatedly doing the same thing and expecting different results. The experience of such repetition, if not the actual result, surely contributes to our collective demoralisation and saps our collective energy to change attitudes and beliefs in ways necessary to achieve an age-friendly world. Second, we allow or even enable promulgation of the anglophone notion of the nursing home as the standard model of care for frail individuals for whom ageing in place poses intolerable risk. In societies around the world, nursing homes remain a mainstay of the healthcare sector aimed at older people. Nursing homes, known by many names (viz. care homes, assisted living facilities, skilled nursing facilities, old age homes, homes for the aged, long term care facilities, convalescent homes), exist on a rough continuum varying in intensity of nursing care and in the homeliness of the facility and its daily routines. These institutions persist in societies, like the United Kingdom, Canada, Australia and the United States, where their historical place is longstanding. Obversely, nursing homes are emerging in demographically rapidly ageing countries where historical precedent is limited. In those societies, responses to care needs for larger groups of people made too vulnerable by life in their own or family homes are merely framed as ‘nursing home’, and models are borrowed from societies where nursing homes are well established. Many gerontological nurses—clinicians, researchers, administrators and educators—lead in approaches to improving and even transforming care provided in nursing homes. Few, however, have transformed the institution as a whole. Moreover, far more of us are unwittingly complicit in replicating a general model of care pockmarked by cruel history and lacking truly contemporary vision. Cruel fails to scan well in relation to the nursing topic. Nonetheless, my intent in using this characterisation is to spark our honest reflection. The origins of these institutions lie in harsh judgement and assignment to government custody. Almshouses, later called workhouses in Britain and poorhouses in the United States, offered shelter to those people lacking means to provide for themselves whom society judged morally deficient (Mullins et al., 1994). Almshouses, workhouses and poorhouses accepted impoverished people of any age once their absent means and morality were established. Later, recognition that some older people lacked means and capacity to care for themselves but possessed what cultural arbiters of the day viewed as moral dignity led to the development of old age homes (Gillick, 1989). Often communities cared for their own, building and administering old age homes imbued with their own cultures. Those communities were commonly bounded by religion, ethnic and ancestral ties, and sometimes by the protection of women. Many such institutions survive today, either as homes for the aged in their communities or as philanthropies reinvented to meet present day needs. We need look no further than the COVID-19 pandemic for confirmation that the unexamined history of the nursing home is a danger to individuals, families and communities. Nurses and their colleagues are among those who endure great risk and too often pay the ultimate price for it with their health, their well-being or their very lives. Yet, this risk and the prices paid are not a result of the pandemic. COVID did not generate poorly resourced nursing homes just as it did not create the ageism that enables blind acceptance of the premature deaths of legions of older people from the disease around the world. Indeed, evidence of the risk inherent in nursing homes today is extolled in myriad national and local investigations of safety and quality. Those investigations are frequently spurred by one or a series of untoward events that breach the threshold of public tolerance. I refer you to the Australian Royal Commission into Aged Care Quality and Safety (https://agedcare.royalcommission.gov.au) as a prominent recent example, though many similar initiatives in other countries and municipalities offer equally useful exemplars. Despite the acknowledged failings of the nursing home as a model of care, I must acknowledge outstanding exceptions that contravene the rule. Some exceptional nursing homes around the world are well resourced, amply staffed and administered with vision. As exceptions, they highlight a commonplace rule of problems in nursing homes. Exceptional nursing homes shine brightly with safe, high-quality care that creates homely comfort for those who live as and for those who work in facilities that say home far louder than they say institution. Just as I do not wish to assail the nurse teacher colleagues and others who aim to redress ageism and catalyse interest to advance nursing education, I have no desire to diminish the incredible and valuable work by nurses and their colleagues who acquit themselves with true distinction in nursing homes around the world. I call out not the individuals but our ahistorical culture and unchanging working patterns. And I ask myself and all of you whether we can or should continue to sustain our foci on the basis of exceptions and not the rule? My fervently dreamt vision is revolution in gerontological nursing. In my vision, we move away from an ahistorical working culture that rests within structures and systems others design and govern. Instead, we move towards historically deeply informed transformation, where nurses lead from inception of new models and institutions to implementation and evaluation and everywhere in between. I imagine us addressing the commonplace while acknowledging the exceptions to that rule for what they teach us in historically informed context. Who knows better than us, the general rules by which care for older people and gerontological nursing operate, both effective and ineffective, in communities, societies and cultures? Consider the two illustrations I offer here. Why document lagging attitudes among our students when we might leverage those well-documented attitudes to generate a starting place for individual intervention, experiential modification and educational innovation? Why pour all our energies into modifying failing nursing homes alone—a task we absolutely must undertake for the safety of those in our care)—without diverting some of our creative energy to reimagining social and health care in new, nurse-led social housing and community-based care models? In these two examples alone, continuing on our current trajectory diminishes our capacity and ability to optimally educate the nursing workforce of the future and threatens the systems of social and health services in which they practise our profession. Critically, continuing as we are strip away hope of a system of elder care we can trust for our own health, well-being and care as we ourselves and those we love grow old. Moving towards our future, then, I offer you a new aphorism, one by which I hope all of us across gerontological nursing work to revolutionise our ageing century: achieving innovation requires knowing history. Put that aphorism into practice and submit your gerontological nursing histories and your transformation and innovation reports to the International Journal of Older People Nursing. Do so knowing our community of readers around the world and the people in their care stand to benefit from what you share. For those seeking reading in history, I offer three recommendations—sadly, only one penned by a nurse—about the American context. Muriel R. Gillick, a practising geriatrician, wrote Old and Sick in America: The Journey through the Health Care System (EBOOK ISBN: 978-1-4696-3525-5), which offers a compelling analysis of our current system of elder care and its historical antecedents. Thomas R. Cole, a noted gerontologist and historian, wrote The Journey of Life (ISBN: 9780521447652) which is a highly readable and very illuminating cultural history of ageing in America. Karen Buhler-Wilkerson, a famed historian of nursing, wrote No Place Like Home: A History of Nursing and Home Care in the United States (EBOOK ISBN: 9780801874796), the definitive history of home nursing in America. Lastly, I hope you might take a moment to share your favourite histories relevant to gerontological nursing with me on Twitter, tagging @SarahHKagan and @InJnlOPN, and on Facebook at https://www.facebook.com/IJOPN/. Include the hashtags #GeroNurses and #AchievingInnovationRequiresKnowingHistory.

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