Colleagues, friends and family often share their stories of health care gone right or—more commonly—gone wrong with me. Their stories illustrate our global needs for a nurse workforce prepared and competent to care for older people. Those who reach out to me begin by saying ‘let me tell you what happened, Sarah’ in an ominous tone. Then they pose simple questions that should not need to be asked. ‘How could this happen? ‘How can they treat me this way?’ ‘Why did this happen to me (or to the person I love)?’ My answers are paltry responses to their plight. We gerontological nurses know well the concerns these stories express and much more. Nascent solutions are at hand but a question we commonly ask ourselves obscures them from view. What question you ask? This one—‘how can we encourage our students to choose careers working with older people?’ Around the world, we talk about encouraging these careers. We study our students' preferences and ultimate choices. Yet we keep returning to the question. This question seems never to fade, despite having been partly answered in various ways, because it belies an insidious half-truth. We hold a misguided conviction that nurses do indeed have a choice about whether to work with older people or not. The stories told to me create a far different narrative. Nurses do have a choice about the extent to which we work with older people. We can choose to specialise in care for older people, settings where all our patients and clients are chronologically older. We who make that choice are gerontological nurses, the professional community addressed by this, the International Journal of Older People Nursing (IJOPN) since its inception. Nonetheless, nurses who do not choose gerontological nursing will still work with and care for older people. To do so well, they must be specifically competent, steering clear of hackneyed notions that simply caring for older people results in effective, evidence-based care that meets the needs and expectations of the people receiving it. Most career choices entailing care for older people are made by default when nurses choose a job by specialty or care setting. One nurse happens to get a job in a nursing home and loves it. Another nurse quietly admits to themselves ‘I do not wish to work with older people’ and seeks a position on an adult surgical ward. Both end up working largely with older people, both by default and one against their desires. Ultimately, the truth is nurses currently think they choose whether to work with older people. They do so, however, without adequate knowledge and understanding of what effective, evidence-based care for older people entails. The extent to which all nursing involves older people spans the specialised to the generalist and on to the supportive. We gerontological nurses are the specialists. Nurses who practice in adult settings including most chronic disease specialties, almost all adult hospital wards, home care, and much of primary care are the generalists. Nurses who work in supportive domains are those colleagues practicing in maternal–child and paediatric settings where older people appear only as caregivers. Here, contact with older caregivers appears inconsequential but, in reality, frequently helps assure the health and well-being of entire families. As a result, proposing that nurses can elect specialties and settings where they can wholly avoid working with older people is simultaneously ageist and untrue. To promulgate this ageist fiction profoundly undermines our social contract. The implicit ageism of our focus on promoting careers in older people nursing arises in the suggestion that avoiding older people is somehow acceptable. Older people are part of every family and every community around the world. Older people are patients, caregivers, or both in every healthcare setting. Nursing, like other health professions, then inadvertently endorses the ambivalent structural ageism that is common across societies when we say ‘choose to work with older people’. No, you can choose to specialise in gerontological nursing, but you cannot avoid working with older people. Our current position on choosing to work with older people suggests that only those making the choice of gerontological nursing need education to improve their relevant knowledge and skills. Those who inadvertently care for older people do so because some or all patients they care for are chronologically old in a setting that declares a specialty other than that of care for older people. They are then expected to provide adequate care just by applying the standards of that specialty. We typically ignore education to shift attitudes and behaviours under the assumption that those who make the choice already hold necessary attitudes and express appropriate behaviours. Simultaneously, we gerontological nurses too often neglect the age-related educational needs of everyone not making the choice for gerontological nursing, leaving their attitudes, behaviours, knowledge, and skills to the teaching of others. The result? Persistent structural ageism in health care with higher costs, lower quality, and dissatisfying experiences for all—nurses, their patients, and their caregivers and families alike. We need a new approach to ensuring global nursing workforce needs in are fully met. Typically, nursing, like the societies in which we live, views ageing populations as adding burden to workloads and creating clinical problems which only some colleagues choose to face. In truth, the problem exists not among older people or in the ageing process. The problem represented by poor healthcare experiences and suboptimal outcomes for older people as well as subpar caregiving support arises in the structural ageism within our education, our health systems, our profession, and those of our fellow healthcare professions. The problem rests with us. Actively dismantling structural and individual ageism is the starting point for fundamental education necessary to all nurses and all healthcare workers. Ageism, in all its myriad forms and in interactions with healthism, ableism, and all forms of social discrimination, is endemic around the world. Ageism proves especially problematic in health care. Many forces contribute to ageism in health care. Nurses and other healthcare workers frequently encounter extreme situations which then begin to feel normative. Encountering older patients in dire health circumstances often enough prompts us to believe that all older people face such situations. Insidiously, we begin to see all older people as frail and ill, stripped of capacity and function. We too quickly see older people as leading meaningless lives save for the mere virtue of having attained their advanced chronological age. Unfortunately, nursing education does little to redress this situation. Our education promotes our compassion and develops caretaking to a level where we too easily strip agency and identity albeit with beneficent intent. In the end, we persist in seeing the older person from our collective vantage point as only a nameless elder facing the usual predicament. We become ambivalently ageist, doing for older people and not with them. Consequently, we repeatedly miss moral and ethical imperatives to support their personhood, understand their perspective, and partner with them in the manner they desire. A new system of education in nursing, one that dismantles ageism and generates generalist and specialist competency in care for older people, is long overdue. Nursing must become anti-ageist as a discipline, a stance taken on behalf of this journal by the editorial team some time ago. Our active anti-ageism offers capacity to change attitudes and then reshape professional behaviours. Having established anti-ageism as a foundation for nursing, we can move forward to distinguish the two strands of competency necessary to improve care for older people. The first is generalist competency, something I and many others often characterise as age-friendly nursing or age-friendly health care. The second is the more familiar gerontological specialist competency. Both competencies can imbue generalist and advanced practice roles globally, ensuring that both registered and advanced practice nurses are ready to provide all levels of care and support needed by older people and their families in every setting. Defining age friendly nursing, along with our anti-ageist stance, requires hard work. Practicing nurses and our educators require education in these two domains as much as our current and future students do. Such education requires new models and frameworks to organise what and how we teach. We might look to the American model of the 4 M's from the national Age-Friendly Health Systems initiative (https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx) or the more international model of the 5 M's of Geriatric Medicine (https://www.healthinaging.org/tools-and-tips/tip-sheet-5ms-geriatrics). We might equally develop a novel nursing model of age friendly nursing or modify current models addressing similar aims of improving care for older people. Regardless of the model we use, age-friendly must characterise all our care. Indeed, our oft-vaunted lifespan perspective anchors the worthy argument that age-friendly must include all ages from birth through death. Why then do we persistently disregard our own values? We must always be prepared and competent to care for the person as their age, identity, social support, health, and well-being warrant. Thus, anti-ageism must make us aware as age-friendly will make us able. Extant models for improving care for older people do exist, offering a foundation on which we might draw. The Nurses Improving Care for Health Systems Elders (NICHE) (https://nicheprogram.org) model is well established and extends beyond the United States to three other countries. However, with only a few hundred institutions participating worldwide and no preregistration curriculum, the reach of NICHE is insufficient to fully meet our needs. Other, more focal initiatives such as End PJ Paralysis (https://endpjparalysis.org) also hold promise, taking science—in this case on mobility and health—effectively into practice. Even with the improvements that NICHE, End PJ Paralysis, and other programmes around the world are achieving, we need vastly more extensive and fundamental transformation. That transformation must make competent care for older people requisite for all, not optional or voluntary. We must speak the truth and then act accordingly if we are to educate the nursing workforce we need. Deep down, we know that passively awaiting the time when, for example, delirium assessment and intervention becomes part of our second nature like taking vital signs or when elder speak—the habit of speaking to older people as though they were children—becomes abhorrent to all, simply will not work. We must actively build our anti-ageist stance with the understanding that healthism, ableism, and all other forms of social discrimination are interrelated. Doing so enables us to integrate our age-friendly advancements into the evolving landscape of truly just social and health care. We must couple gerontological nursing education by choice for those who aim to specialise with a new mandate of age-friendly education for all, generating robust age-friendly nursing that matches or even exceeds what we are achieving in gerontological nursing. Here at IJOPN, our anti-ageist stance informs what we publish. We already advise our authors not to problematize older people and ageing populations. Ageist terms of reference like ‘elderly’ are not accepted. More specifically, we scrutinise manuscripts that report only students' attitudes towards older people and caring for them, urging authors to study interventions and examine implications and actions. With the hope that IJOPN draws many readers and prospective authors who do not identify themselves as gerontological nurses, this editorial represents our next step in contributing to a more just, age-friendly world. We invite authors synthesising evidence in anti-ageism and age-friendly domains relevant to nursing and health care to submit their manuscripts. We encourage nurses and interprofessional teams defining and testing globally relevant age-friendly social and health care education and practices to consider IJOPN as a potential venue for disseminating their research. And we welcome authors designing, implementing, and testing age-friendly models and curricula to think of submitting reports of those innovations to IJOPN. As always, we embrace opportunities for conversation, particularly through social media. We at IJOPN want to hear from older people, advocates, educators, clinicians, and researchers about their thoughts on anti-ageism, age-friendly nursing, gerontological nursing, and education necessary to achieve all three. You can find us on Twitter at @IntJnlOPN and on Facebook at https://www.facebook.com/IJOPN/. Please use our hashtag #GeroNurses and add the hashtag #AgeFriendly when responding to this editorial. Note that this and all our IJOPN editorials are now free-to-read whether you subscribe to the journal or not. Making our editorials accessible to all readers is a change that we hope helps generate a deeper conversation, and spurring transformation. We look forward to hearing from you. The author has no conflicting or competing interests to disclose. Data sharing not applicable to this editorial. No datasets were generated or analyzed in preparing it.

‘Who here is a patient?’ I ask groups of clinicians and scientists I meet. The response is predictable. Mindful of roles as nurses or scientists, almost no one says, “I am a patient.” A few—most being treated for chronic and often serious conditions—respond affirmatively. The truth, and with it an understanding of power, visibility, and inclusion, escapes most everyone. In reality, we are all patients. We all receive healthcare, assuming the role of patient if only briefly once a year. Yet what it means to be a patient is pushed frommemory in the moment. To recollect that meaning is to feel afresh discomfort, anxiety, and confusion, but more rarely comfort. The experience of patient is at once unique— who I am—and universal—how I am human. Forgetting our inner patient is not simple oversight but a complex social phenomenon. Responses to my question about our identities as patients are predicated on social roles and power dynamics. The politics of power reach deep into contemporary healthcare. Structures and processes reinforce hierarchy and control. Increasingly, research reveals the extent to which power dynamics undergird structural and individual discrimination and depersonalizing experiences, while perpetuating poor outcomes throughout healthcare. Yet, a fundamental element of this dynamic—that of patient—garners scant attention. The language of patient sits, unexamined, across cancer care and science. We aim to improve patient experience by being patient-centered.We recruit patients for our studies.We typically fail, however, to explicitly recognize that patients are people filling a social role in that moment. In our roles as nurse scientists, we strive for work-life balance. The corollary of patient-life balance seems almost absurd. Nonetheless, that absurdity underscores the extent to which the person is invisible in cancer care and science. Uncritical use of the term patient renders the person in cancer care invisible. Using patient in a study works well if the interest lies, for example, in describing interactions with nurses. However, using patient in a study of self-care or family functioning is arguably flawed given the focus on life outside of cancer care. After all, patients are not patients when at home. Preponderant use of patient quickly slides into depersonalization, risking discrimination. Patient implies vulnerability, problems, and needs to bemet with the authority of our systems of care. Authority is an expression of power, clearly seen in compliance with—or adherence to, in contemporary rephrasing—treatment, education, and care we use to address patients’ problems and needs. To view patients as merely the sum of problems and needs is to strip them of personhood, objectifying the individual and categorizing by nominal characteristics. Discrimination often emerges in the “too” judgment linked to patient. Inmy area of research, “too” is framed as “the patient is too... [old, frail, impaired, dysfunctional].” All human beings are vulnerable and experience problems and needs. To see any individual as a tally of those qualities makes them less than they are. All people also possess strengths, accomplishments, and mutuality. Overcoming limitations of patient in research challenges us, beginning with realizing risks associated with using an apparently innocuous, factual term. Embracing our own inner patient paradoxically allows us to begin untangling complexities of patient in cancer nursing science. Comprehending our own experience of patient brings us closer to knowing that we cannot comprehend all patient experiences. Reflexively, we become better appraisers of what we aim to study and how patient pertains. With our inner patient firmly in mind, untangling patient in cancer nursing science then prompts action. First, replace patient with person or person living with or after cancer unless patient is specifically germane. Next, consider appositeness of other social labels. For instance, age, race, and sex are frequently coupled with patient—“older adult patient” is one I often encounter—when generational, racial and ethnic, and gender identities are more relevant to many cancer nursing studies. Lastly, conducting research involving persons living with and after cancer, anchored in personhood, warrants reflecting on their participation in our science. Honoring participation in full merits including new roles of advisor and coinvestigator to redress power dynamics and fulfill the promise of nursing for better cancer care.

International Journal of Older People NursingVolume 15, Issue 1 e12308 EDITORIAL Clarifying our vision of older people nursing for the new decade Sarah H. Kagan PhD, RN, Corresponding Author Editor in Chief skagan@nursing.upenn.edu University of Pennsylvania, Philadelphia, Pennsylvania, USASearch for more papers by this author Sarah H. Kagan PhD, RN, Corresponding Author Editor in Chief skagan@nursing.upenn.edu University of Pennsylvania, Philadelphia, Pennsylvania, USASearch for more papers by this author First published: 08 February 2020 https://doi.org/10.1111/opn.12308Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume15, Issue1March 2020e12308 RelatedInformation

The triple threat of ageism, healthism and ableism loom larger than ever in this, a truly extraordinary year, a year marked by worry and sorrow. Nurses caring for older people and their loved ones around the world face compounded challenges. Disproportionate morbidity and mortality in older populations raise few questions and fewer actions. Isolating older people, particularly those who are frail, comes more easily than ever. Understanding, providing and studying the how, why, what and where of improving care, health, function and daily life with and for older people and their family caregivers is more consequential now than ever before. The extent of mismatched, ineffective and deleterious care lies freshly excavated at our feet. And we, gerontological nurses and our colleagues within and beyond our profession around the world, are reeling. What devastation—current or predicted—to tackle next? The problems pile up faster only than the world’s collective fatigue. Closing this year and anticipating the next affords us all a moment to pause and take stock. What next? Which problem? What action? Perhaps the answers lie not in which problem but in where to find strength and solace. Problematising ageing and later life seems ubiquitous. The cultural nuances may shift but the notion of problem appears in all sorts of guises when ageing and older people are the topic of discussion. The synonyms used for problem are endless but the result is the same. Ageing is a decline. Older people are dependent. Elder care drains resources from elsewhere. Older people are a burden. Theoretically sound, data-driven counterarguments—from the neuroscience of wisdom to the longevity economy—often land on proverbially deaf ears despite compelling evidence. The means to refreshing ourselves, colleagues, family and communities for all that 2021 requires likely lies outside the rational and the empirical. The weariness of people and communities around the world—a consequence, I posit, of life in the pandemic acting upon active and latent ageism, healthism, and ableism—merits more than an intellectual approach. Our spirits are frayed and our souls weighed down. Spirit and soul need beauty. The beauty of human life and of the world in which we live. The ageing services and elder care communities are repositories of beauty, be it often hidden from view. Those of us who choose careers in ageing frequently arrive to serve and to care because we see the remarkable but commonly dismissed strength in aged bodies, the beauty of human wisdom and sage judgment, and the eloquent stories of lives many decades long. Similarly, we in these communities frequently turn to creative expression. Creativity and expressions of individual and collective creativity are hallmarks of many skilful encounters with elders and of growing numbers of successful programs employing the arts. In our daily comportment as nurses, many creative acts are taken for granted. We play favourite music for the older person in the last days of their life. We arrange outings to museums, concerts and recitals. Other creative actions take centre stage (pardon my pun). Examples are many and, here at the International Journal of Older People Nursing (IJOPN), we offer up some of our favourites. Assumpta Ryan, of Ulster University and the IJOPN Editorial Board of this journal, collaborated with theatre professionals to bring her research into life with dementia in the 2019 play ‘Songbirds’. IJOPN Editorial Board member Susan Shifrin conceived of and runs the program ARTZ Philadelphia which brings interactions around arts and culture to people living with dementia and other conditions in their own homes, in neighbourhoods, and in nursing homes and other residential facilities. Social Media Editor Anna Carapellotti, a dancer and a researcher, transforms how people live with Parkinson’s disease and similar conditions with dance. Several notable arts programs and the effects achieved among older people are disseminated in the volumes of the International Journal of Older People Nursing. The arts. Our relief and our rising in dire times lies in the arts. The arts sustain us as human beings, if only for a much needed moment of repose. The beauty, interest and emotion of so many different arts the world over hold the power to provide so much of what we and, indeed, everyone around the world need. Our solace lies in the arts. Breathe the sigh of grief released in hearing a poem read in memory of those we have lost brings. Feel the relief of dancing, loosening stiff joints and fresh sorrows. Marvel at being transported at the impact of glimpsing and being enthralled by a photograph, a painting, a symphony or a song. Our strength rests in the arts. Nursing holds a long treasured but sometimes meandering dialogue about our art and our science. Science gets the publications and the press. Art gets the myths and imaginaries. In reality, our art—the tacit knowledge of our embodied practices and relational comportment—is a source of strength. Paradoxically, the art of our praxis and our practice may entail making and sharing the arts—music, dance, painting, photography, poetry, storytelling and many more. Yet, when pressures escalate in the bio-medically dominated systems of care where we work, we too quickly revert to the systemic normative focus on problems. We place our salutogenic true identity to the side and, simultaneously, diminish when and how we act on our perspective of health as far more than the absence of pathology and a return to some notion of ‘baseline’. As consequence for casting our true collective self to the side, we easily slip into ageist, healthist and ableist understandings. Ageing is a problem to be solved. Frail and ill elders are vulnerable and without strength, always in need of care and never able to reciprocate. I beg to differ. Such discernments are fundamentally nihilistic, leaving us no future as an aged world. On the contrary, no one is without some strength, even if that strength remains hidden from self and others. Obscured, dormant strength has only to be uncovered. Even death may be reflexion of strength. The arts, as expressions of creativity, emotion and spirit, uncover strength. For us as nurses and for our colleagues and—most critically—for older people and those who love them, I ask you to imagine. Imagine the possibilities of the arts. Telling our stories to glean wisdom. Hearing our poetry to learn lessons of the soul. Listening to music for healing and harmony. Painting or sculpting our inner vision or appreciating that of another. Dancing our way to freedom, if only for the next few beats. We will find in ourselves and those in our care capacities—strength and flexibility of the soul, the mind and the body—we might never recognise without clarity brought by art. As this unparalleled year closes and the next begins, I entreat you to embrace the arts. Perhaps you might begin with the music of a solstice celebration in your own or someone else’s cultural customs. Maybe you and a wise elder may dance in the New Year. Or might you partner with local artists and develop an arts program for elders and others in your institution, in your community? Whenever and wherever you find yourselves—our IJOPN global community—in need of respite and seeking fortification, look to the arts. Embrace the arts for all that these varied and marvellous traditions contribute to human existence, bringing it to life. From all of us here at IJOPN—the editorial team, the editorial board and the publishing team—we wish everyone a bright New Year of safety, health, peace and beauty where hardships abate and succour replaces suffering. Thank you for all that you do to make our world a better place for people of all ages. We hope for your solace and your strength.

Every person, for whom we care as gerontological nurses, is an older person. Indeed, the mental image we hold of our prototypical patient is always of an older person. For us, older is the normative developmental state of being—“those are the people for whom I care,” we think to ourselves. This thinking is synonymous with our gerontological perspective, forming the core of older people nursing. Our colleagues in specialties and practice settings beyond gerontological nursing face a different reality, a dissonant daily experience. The mental image they hold of their prototypical patient—their “every patient”—is generally that of a young or midlife adult. However, given current ageing demographics and non-communicable chronic disease (NCD) epidemiology, their patients are in fact most often older. My clinical specialty of oncology nursing is a good example of such dissonance. In oncology, care for older people persists an optional sub-specialty practice. The sub-specialty designation stands in opposition to the reality of cancer epidemiology and ageing in clinical practice. The global epidemiology of cancer is shifting quickly (Bray et al., 2018). People over 65 years of age constitute the majority of people diagnosed with cancer in most regions of the world (Bray et al., 2018). Moreover, that same age group represent the great majority of cancer survivors in many societies around the globe (Shapiro, 2018). Critically, research with young people who survive childhood cancers shows early expression of clinical frailty, prematurely ageing these young people (Shapiro, 2018). Thus, despite clear evidence that oncology nurses routinely care primarily for older people along with younger people who may be biologically older than their years, the mental model of a prototypical cancer patient remains firmly cast in midlife. As a result, significant efforts to increase gerontological competence across the oncology workforce often garner less return than hoped. Nurses in other specialty practices and settings contend with similar. The epidemiology of other CNDs suggests that nurses in specialties across acute, ambulatory and community settings care for aged populations but do not view themselves as specialists in care of older people. Nurses, like me and countless others around the world, who practice outside of aged care settings, are in effect gerontological nurses. Nonetheless, many of us do not think of ourselves as such or feel a sense of gerontological competence. Our professional identity and skills may be at odds with the needs of our patients and their families. Conversely, gerontological nurses possess much to offer our colleagues in other specialties and settings. Our gerontological science and expertise caring for older people, along with experience in age- and dementia-friendly initiatives, are a treasure trove from which we are able to share generously. Looking forward, I challenge us as an international community of gerontological nurses—clinicians, scientists and educators alike. Let us redouble our outreach to our nursing colleagues to help them become proud and successful gerontological generalists, replete with foundational competencies and a positive vision for the future. Gerontological nurse researchers, educators and clinicians alike possess an incredible range of knowledge and skills as well as essential approaches and models. All are profoundly useful when translated to settings beyond aged care. We easily differentiate person-centred practice from patient-centred care. Similarly, we quickly dismiss myths and mystery surrounding the “3 D's”—delirium, depression and dementia—bringing clarity to care for elders experiencing these conditions. The examples are limitless; we have so much to share. Bringing clarity to dissonance begins with sharing our resources. So much of what we take for granted aids colleagues establishing gerontological competence in practice, education and research. Consider offering seminars, workshops, tools, and assets like favourite websites and publications to colleagues. Extend invitations for observation and consultation to better explore translation of evidence and dissemination of best practices. In taking up this challenge, let us disseminate through social media how and what we are sharing. Tweet about it to the International Journal of Older People Nursing at @IntJnlOPN, using our favourite hashtag #geronurses and adding two new hashtags #gerocompetence and #geroshare. Post your seminars, workshops and other events, tagging our Facebook page (https://www.facebook.com/IJOPN/), using the same hashtags. Suggest to your colleagues in other specialties that they use these hashtags too as well as those designating their cross specialty focus. In oncology, for example, that hashtag is #gerionc. Thank you for your generosity in time, energy and spirit. I look forward to lively dialogue about dispelling dissonance, gaining clarity and building gerontological competence.

Nurses around the world are aware that our world is ageing. Our literature commonly anchors arguments for science, education, practice, and policy in ageing populations demographics, citing the problems those demographics beget. However, grounding focal programs and specific initiatives in general claims about shifting age demographics misses two key points. First, demographics are rapidly moving to aged proportions, breaking the threshold where older people represent more than one in five across a population. Population changes in such magnitude warrant pervasive action to advance nursing and improve health care. Second, problematizing age demographics creates a theoretical null. Considering older people only in terms of dependency and burden results in a future with few possibilities as the world's population continues to age. As leaders in health care, nurses can ill afford to ignore the implications aged demographics and problematizing ageing. If we are truly to lead, we must take up a different vantage point and begin to reshape health care. Many of us became nurses when analysis of the implications of ageing demographics constituted a future concern, not an immediate reality. Little in our education prepared us for practice in an aged world. Caring for older people lay among many specialties from which we selected rewarding careers. The professional paths laid before us turned out to include unexpected opportunities, challenges both personal and professional, and options that defied prediction; still most of us are likely not ready for nursing in an aged world. Decades ago, few nurse scholars along with other health care leaders fully predicted what shifting age demographics meant for health care. That older people are always majority health care users in ageing and aged communities seems obvious now. Yet, few of us selected care for older people as our specialty in the profession. For those who did, that specialty generally led to a path of segregation. Gerontological and geriatric nurses rightly claimed care for frail older people, most living in residential facilities. Older people less frail and living in other communities commonly received health care designed for young people from nurses who knew only basics about ageing and care for older people. The same remains true today. Older people are certainly our primary population in most settings, save those dedicated to maternal-child and youth care. Most health care remains modelled on a youthful norm where older people constitute a specialty population. Similarly, shortages of nurses prepared to care for older people continue unabated. Thus, nursing is largely unprepared to lead in health care for our aged world and to manage an ageing workforce. Other realities associated with advancing age demographics are generally less obvious and, conversely, more contextual. Grandparents are increasingly primary caregivers for their grandchildren in many areas of the globe (Dolbin-MacNab & Yancura, 2017; Hayslip, Fruhauf, & Dolbin-MacNab, 2017). Just how children's and family health care adapts to that reality is less clear than the trend itself. The nursing workforce is ageing rapidly in many societies, a phenomenon addressed in this journal during recent years (Phillips & Miltner, 2014; Stichler, 2013; Utriainen, KyngÄS, & NikkilÄ, 2011). Robust, proactive responses to our ageing workforce are less evident across practice settings in various societies. Everywhere we look in nursing and health care, direct and indirect consequences of movement from ageing to aged demographics abound. Such consequences get a good deal of notice in certain circles; however, consistent and tangible change appears slow to follow. What, then, are we to do in this century of the aged world? The answer lies, I believe, in reframing what we do as explicitly age-friendly. Age-friendly is a term over a decade old. The World Health Organization (WHO) uses the term in ways familiar to many. The WHO proposed developing age-friendly cities (Organization, 2016) and disseminated a model for age-friendly primary care (Organization, 2004). Most recently, leading organisations in the United States where I live, took up age-friendly to reshape our health care organisations (Fulmer, Mate, & Berman, 2017; Mate, Berman, Laderman, Kabcenell, & Fulmer, 2018). Here, age-friendly health systems are building on models from nursing such as transitional care (Naylor et al., 2018) and medicine where they drew on the Five M's, modified for age-friendly care as Four M's (Tinetti, Huang, & Molnar, 2017). Elsewhere in the world, examples of age-friendly, senior-friendly and dementia-friendly health care establish a foundation for local clinical application (Chiou & Chen, 2009; Parke et al., 2017; Wong, Ryan, & Liu, 2014). However, two core principles underlie each specific interpretation and local application, grounding age-friendly. Age-friendly, as an approach, is often locally defined. Nonetheless, two core principles are readily apparent. First, age-friendly is positive. The mere use of the word “friendly” connotes a positive or appreciative stance. Nary a “silver tsunami” nor an “elderly problem” is welcome in a genuinely friendly perspective. Second, age-friendly is inclusive, not exclusive. Age-friendly is not Elder-friendly or Older People Friendly; it includes all ages. Both the classical model of age-friendly from the WHO and newer applications of the term speak to creating inclusion and access for people of capacities and abilities. Similarly, the dementia-friendly movement specifically addresses alterations in cognitive and associated functions. Positive and inclusive characterizes age-friendly care for an aged world. Shaping care, communities, and everything in between as age-friendly creates benefits that reach people of all ages, capacities, and abilities. I describe age-friendly care, especially to audiences who are wondering about its value, in this way. Imagine you are redesigning public transit to meet the needs and preferences of your most frail and functionally needful older users. Achieve that and so many others then rejoice. The young mother with three children under five loves age-friendly as much as the emerging young adult with mobility differences does. Contemplate the transformation of public transit to meet everyone's needs using the frailest older users as your barometer and you soon see how to approach health care anew. Age-friendly, as a perspective, cannot generate the specifics of how and what to change. Oddly, the majority of those specifics are already available. Application is often limited, confined to one specialized program or initiative rather than broadly cast transformation. Exciting local initiatives such as the new “End PJ Paralysis” campaign (Dolan, Gordon, & Moore, 2018) and the John A. Hartford Institute's Geriatric Resource Nurse Program (Fulmer, 2001) are there, ready for your consideration and adaptation to most any setting where the resource is relevant. As a nurse manager and administrator, the tools to make age-friendly a reality in your setting are simply awaiting the contemporary perspective, shifting from negative and exclusive to positive and inclusive. Shaping nursing's leadership in age-friendly care is our shared horizon; let us move towards it together.

Gerontological nurses, and indeed all nurses practicing today, walk a tightrope of which we are generally unaware. Stretched across the centuries, this tightrope strings us between the past where the modern hospital introduced the groundbreaking notion that those who entered could survive and even recover and the present where an aged demographic demands transformation of both health and social care. The modern hospital model is now hundreds of years old. I practice in the United States first hospital, founded in what were then the English colonies. Pennsylvania Hospital stands on its original site and dates to 1751. Founded by the pre-eminent scholar and scientist Benjamin Franklin and his physician colleague, the notable clinician Thomas Bond, it thrives today as an institution so many in our surrounding community see as their personal hospital, a source of genuine care. My pride in working at my country's first hospital is undimmed by my analysis that these institutions must move from the centre of our healthcare systems to the periphery if aged societies are to meet their needs for health care. The modern hospital is a remarkable 18th-century innovation. At the time, hospitals helped to realise possibilities inherent in allopathic Western medicine. In well-run hospitals, and here, I refer to Nightingale's Notes on Nursing (Nightingale, 1860), people could enter a place of sickness and survive to recover and rejoin daily life. Created in an era of youthful demographics where injuries and acute rather than chronic illness dominated health concerns, the modern hospital still best addresses the needs of young populations. Foci and processes are inherently intensive and episodic. As a result, hospitals most easily care for youthful individuals with unexpected, time-limited problems superimposed on good health, unrelated to frailty, multimorbidity, or chronicity. Here in the 21st century, ageing and chronicity rule the day. Ageing demographics, with 14% to 20% of a population over age 65, and aged demographics, with 21% and more of a given population over that age, correlate with epigenetic states like those of frailty and cancer strongly linked to ageing. The intensive, episodic care delivered by hospitals aligns poorly with the steady, relationship-driven health care necessary to prevent complications and promote function in such states. Efforts to make hospitals and the ambulatory clinics that now support them age and dementia friendly testify to the recognised mismatch between hospitals and the needs of older populations. Hospitals remain at the centre of most healthcare systems around the world despite awareness and efforts to mitigate mismatch. That centrality, combined with shortfalls resting within other elements of those systems, ensures that older people remain their largest group of users. In parallel, we nurses represent the largest hospital workforce, although we no longer practice using 18th-century models. My appraisal suggests we rely instead on a mid-20th century-approach albeit with use of some 21st-century technologies. Today, our nursing practice with older people and their families constantly contends with the centrality of hospitals. We exert enormous effort, pushing on institutional limitations and creatively drawing out adaptable dimensions of hospitals and the systems that surround them, such as Medicare home care here in the United States for which hospital discharge remains the common trigger. Our efforts generate impressive results. All sorts high profile campaigns, educational programs and public service messages aim to make hospitals less risky for older people. The current campaign to end “PJ paralysis” (https://www.england.nhs.uk/2018/03/70-days-to-end-pyjama-paralysis/), aimed at curbing deconditioning among older patients, is among my favourite examples. Creative and catchy, the campaign captures the very dilemma I highlight here. Hospitals set up all sorts of peril and predicament for older people, as well as their younger counterparts who live with complex health needs. We nurses are eminently able to find ways to modify risk and work around limitations we encounter in these institutions. Indeed, we must continue to do so until we succeed in sufficiently transforming healthcare systems. We await that transformation, a time where the place of acute care moves from the centre to the periphery in both expectations and operations in health care. The time where urgent or emergent admission of any older person is a last resort, an extreme measure taken after community-based home and ambulatory resources fail to address needs, is not yet reality. In the interim, our societies count on us to serve as their guardians in healthcare institutions and systems never intended for ageing and aged populations. Expectantly anticipating a revolution in healthcare systems alone is ineffective. Transforming healthcare systems requires our dedicated leadership and vision. Nursing, easily understood through our metaparadigm (Fawcett, 1984) as well as other defining treatises, acts from a place of understanding that health and well-being situate the person in social context—a personal environment—across the lifespan. In our soon to be aged world, concerns such as loneliness and primary malnutrition, both considerable causes of ill health among older people today, dominate in unprecedented ways. These conditions underscore the relevance of nursing in ageing and the mandate to integrate health and social care. Our insights, as nurses and especially as gerontological nurses, are essential to creating institutions and recreating systems that move away from allopathy and towards an inclusive paradigm for health and well-being. With our metaparadigm at hand, we can leverage personally, social and spiritually determined understandings of health and well-being. We walk a tightrope spanning the 18th and the 21st centuries each day as we care for older people and their families. Let us be mindful of those centuries, maintain our balance and keep our eyes firmly on the horizon of shared aims for optimal health, function, and well-being for us all.

Chapter 31 Diversity and Cultural Competence Dr. Tyrone A. Holmes Ed.D, Dr. Tyrone A. Holmes Ed.D president tyrone@doctorholmes.net. Search for more papers by this author Dr. Tyrone A. Holmes Ed.D, Dr. Tyrone A. Holmes Ed.D president tyrone@doctorholmes.net. Search for more papers by this author Book Editor(s):Ryan Watkins Ph.D., Ryan Watkins Ph.D. associate professor active member vice president visiting scientist George Washington University in Washington, D.C., USASearch for more papers by this authorDoug Leigh Ph.D., Doug Leigh Ph.D. associate professor doctorate technical director chair member Pepperdine University's Graduate School of Education and Psychology, USASearch for more papers by this author First published: 23 November 2009 https://doi.org/10.1002/9780470587102.ch31 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Summary This chapter contains sections titled: Introduction Description What We Know from Research When to Apply Strengths and Criticisms Recommended Design, Development and Implementation Process Critical Success Factors Summary References Handbook of Improving Performance in the Workplace: Selecting and Implementing Performance Interventions, Volume 2 RelatedInformation

Evidence-based practice (EBP) holds a firm, central place in nursing. Lauded by investigators and practitioners alike, many nurses point to Florence Nightingale as the first to highlight evidence in practice (Mackey & Bassendowski, 2017). Today, most gerontological nurses value EBP, recognise unmet need for evidence in care for older people and caution against classifying evidence too rigidly (Rycroft-Malone et al., 2004). We realise older people receive our care in varied settings and at varied points in their lives, under myriad conditions. Within the plurality that is gerontological nursing practice, we guard against overly simplistic and narrowly determined understandings of the “who, what, where, when and how” that constitute EBP. Typically, EBP flows from science and investigators in the form of syntheses of single primary data sets and evidence gathered from across a set of studies. Clinicians and practitioners working in domains where that evidence is relevant benefit directly. They employ appropriate primary research findings and, more often, evidence syntheses such as systematic reviews and qualitative meta-syntheses in their practice. The plurality and multiplicity of gerontological nursing frequently outstrip available evidence, especially when empirical and quantitative terms of reference delimit evidence. Nonetheless, these unmet needs impel nurse scientists and others to continue their quests for discovery, filling reserves of necessary evidence. Our embrace of EBP parallels efforts to effect alignment between research and practice within nursing. Nursing struggles still, as in times past, in bridging a divide between research and practice. Many individual nurses and institutions display bold efforts to create relationships and build dialogue and action between research and practice. Think of the nurse researchers working in practice settings around the world to gain a sense of how far these efforts reach. Arguably, however, the divide between nursing research and practice is, when framed at the level of discipline and profession, smaller than ever before. Whether that bridge effectively reaches the many spaces where we nurse older people is less certain. Fewer long-term care institutions as opposed to acute care hospitals, for example, envision such roles and find the resources to realise them. Taking stock of the state of EBP and the amalgamation of research and practice highlights the broadly unidirectional nature of each campaign. In the same way that EBP flows from science to practice, practice is the place where research is integrated. Research teams less often include nurse clinicians than clinical programmes include a researcher or scientist. True, some research studies do incorporate team members who represent clinical and consumer or service user perspectives. The reverse relationship, like that in EBP, is far more common. The limitations of health and social care in effectively meeting the needs of older people, their families and communities warrant radical reappraisal and realignment of current structures and processes to achieve aims of improvement. Gerontological nursing, as a community of practitioners, educators and researchers, possesses knowledge, skill and perspective needed to effect such change. In a world soon to be aged and super-aged in many regions of the globe, we see phenomena—average age on a hospital ward of over 90, for instance—and contend with challenges—promoting independence at home for multimorbid yet quite functional elders—colleagues may not yet envision as even possible. To support requisite shifts in practice, education and science, I posit altering the course on which evidence flows in EBP and in the integration research and scientists into practice. Practice in care for and with the highly heterogeneous group labelled older people generates rich and varied funds of evidence. Evidence generated by practice spans the relational and aesthetic to the standardised and benchmarked along with almost everything that lies between. I suggest now, today when we contend with the possibilities held in a super-aged world, is the time for evidence-generating practice. Public health, along with a very few other disciplines, predates us here with their call for practice-based evidence (Green, 2006). Let us then lead nursing in this drive for current and nimble connections between and among practice, research and education to achieve the betterment of health and well-being at all ages for everyone around our soon to be aged world. As IJOPN Editor in Chief, I challenge gerontological nurse clinicians, scientists and educators—too often left out of debates and positions about evidence—to help define evidence-generating practice in care for older people. Foundations for this work are clear, existing in a rich and varied literature that reflects how we appraise the scope, quality and influence of our practice, collecting all of that and more as the evidence we seek. Building from those foundations to re-establish the flow of evidence as dialectic; creating platforms for nurse clinicians holding meritorious positions in research teams; and developing novel standards and standard bearers for evidence-generating practice in gerontological nursing emerge as next logical steps. Let us go forward together.