Author: Heise, Barbara A; Johnsen, Vickie; Himes, Deborah; Wing, Debra
Date published: May 1, 2012
Journal code: NHCP
THE S I LV E R T SUNAMI I S HE R E . In the United States alone, 10,000 people a day are turning 65 years old, with this rate projected to continue for the next 19 years (Alliance for Aging Research, 2006). By 2030, all of the Baby Boomer cohort (born 1946-1964) will be beyond the 65-year-old mark and will represent approximately 20 percent of the US population, or 72.1 million people (Administration on Aging, 2010). Coexisting with an increase of older adults is a shortage of health care workers trained in geriatrics (Lun, 2011). Professionals trained in gerontology and geriatrics are essential to provide care and support for older adults, allowing them to remain independent (often called aging at home). Despite the growing need, few nursing students specialize in gerontology. The Institute of Medicine (2008) reports that fewer than 1 percent of registered nurses hold a geriatric specialization or certification.
Given the high demand, why do relatively few nursing students select this field? Many reasons have been given. Negative or neutral attitudes toward the elderly are common in our youthoriented society (Koren et al., 2008; Ryan & McCauley, 2004/2005). Health care has done a great job of prolonging life, but society has done a poor job of valuing that older life (Holroyd, Dahlke, Fehr, Jung, & Hunter, 2009), and negative bias (ageism) is common (Holroyd et al.; Moyle, 2003; Phelan, 2011). Anti-aging strategies thought to slow, stop, or reverse the aging process, such as facelifts and Botox injections, may promote ageism and lead to devaluing the health care provided to older adults (Holroyd et al.; Phelan, 2011). Allan and Johnson (2009) found more negative ageist attitudes among males than females. In a classic study, Slevin (1991) reported more negative attitudes toward the elderly among young nursing students than their non-nursing counterparts.
Nursing students' lack of interest in older adults may result from a lack of awareness of the opportunities available in the field of gerontology (Gross & Eshbaugh, 2011). Nurse educators' personal negative attitudes toward aging and long-term care facilities, as well as students' negative attitudes that nursing homes were "beneath" RNs, affected attitudes toward clinical placement in long-term care facilities (Schrader, 2009; Sheffler, 1998).
Changing negative attitudes toward older adults and thereby building capacity, as well as capability for gerontological health care workers, has been the focus of research. Knowledge about and exposure to the elderly impacts attitudes. Among social work students, Cummings, Galambos, and DeCoster (2003) reported that increased knowledge of the aging population through undergraduate gerontology courses, along with increased frequency and improved quality of older adult contact, were positively associated with selecting aging-related careers. At a minimum, students became aware of ageism and how their projected area of expertise related to older adults. Exposure to older adults through focus groups (Sandel, Cohen, Thomas, & Barton, 2006), face-to-face meetings (Krout & McKernan, 2007), service-learning (Gutheil, Chernesky, & Sherratt, 2006), undergraduate gerontology courses (Funderburk, Darmon- Rodrigues, Storms, & Solomon, 2006), email pen pals (Chase, 2011), and clinical practicums (Olson, 2011; Sheffler, 1998) have been shown to improve student attitudes toward the elderly and enhance interest in working in age-related fields. Gonzales, Morrow-Howell, and Gilbert (2010) found that socializing through an art program changed attitudes toward older adults among medical students but did not influence career plans. In a study of undergraduate college students by Eshbaugh, Gross, and Satrom (2010), quality relationships with unrelated older adults and a low level of death anxiety among young participants predicted positively the likelihood of working with older adults. A mixed-methods study by Fox and Wold (1996) found that with exposure, nursing students discovered that they shared common qualities with older adults (intergenerational commonalities) and that older adults can contribute to society (intergenerational sharing).
While there is no question that gerontological nursing content is vital in nursing curricula, questions arise regarding where to place that content. Some nursing programs advocate a stand-alone nursing course, positioned at the beginning of the program and infused throughout the remaining courses (Jansen & Morse, 2004), while others recommend a capstone course at the end of the nursing program. The primary concern regarding geriatric content integrated into already established courses is that vital gerontology content may be minimized (Thornlow, Latimer, Kingsborough, & Arietti, 2006).
Clinical placements for exposure to older adults have also been examined with equivocal results. Marsland and Hickey (2003) found that caring for the elderly in long-term care (LTC) facilities was perceived negatively by nursing students and that the clinical experience only served to reinforce negative perceptions. Some nursing programs advocate for not using LTC facilities at all. Clinical experiences with healthy, communitydwelling older adults have been shown to positively improve student attitudes toward working with older adults and should be part of the gerontological nursing experience (Burbank, Dowling-Castronovo, Crowther, & Capezuti, 2006; Furze, Lohman, & Mu, 2008). However, a concern regarding clinical placements with only healthy older adults is that while students may have a happier experience, their underlying negative perceptions of the elderly when working with frail and ill older adults in other settings may not change. Some studies have shown that nursing home clinical placement has been found to improve nursing students' negative attitudes toward the elderly when clinical placement occurred in quality LTC facilities and clinical instructors had positive attitudes (Chen, Melcher, Witucki, & McKibben, 2002; Hartley, Bentz, & Ellis, 1995; Mueller, Goering, Talley, & Zaccagnini, 2011; Sheffler, 1998).
Attention to intergenerational ways of thinking may enhance attitudinal change. Millennials (ages 16-29) and Generation Xers (Gen Xers, ages 30-44), place a high value on work/life balance or making time for fun, in contrast to Baby Boomers (ages 45-65), who emphasize work as an overriding theme (Wieck, 2011). The Pew Research Center (2010) found that most Millennials see caring for an elderly parent in their home as their responsibility if the parent should so desire. An emphasis on older adults in a healthy play setting and in a work setting, such as LTC, may improve attitudes toward older adults among Millennials and Gen Xers.
All students will encounter older adults when they become RNs in essentially every practice location. Older adults, as grandparents, are even involved in areas such as pediatrics and obstetrics. Thus, common negative attitudes regarding older adults need to change so that more students will consider geriatric nursing as a specialty. Clinical placements that focus on the generational differences (Millennials, Gen Xers, Baby Boomers) in ways of learning and perceiving may enhance attitudes toward older adults.
Changes to the Curriculum This article reports on our experience in championing gerontology in a private university that graduates baccalaureate nurses. The College of Nursing (CON) identified a faculty member as the gerontology content expert for the nursing program, as well as for a university-level Gerontology Program Committee that promotes an interdisciplinary gerontology minor or certificate. Nursing successfully identified a pathway for nursing students to be included in obtaining the gerontology minor. Nursing students reported that having the minor improved their marketability in obtaining jobs they desired.
After the entire nursing faculty was surveyed to determine the extent to which gerontology content was taught during the nursing program, resources were mailed to all faculty to promote such content where appropriate. Resources included case studies, PowerPoint slides, and Internet links to organizations such as the John A. Hartford Foundation and the National League for Nursing (NLN). (See Sidebar.) Faculty were resurveyed the following year to determine if they used the additional information in their course content. Some faculty did take advantage of these resources and even changed the medical-surgical textbook to include one that contained a gerontology focus section in each chapter.
A stand-alone, introductory gerontology nursing course, Nursing Care of Older Adults, underwent major revisions based on the AACN Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults (2010). Offered originally during the first semester of the six-semester nursing program, the course consisted of a didactic portion, a clinical in a LTC facility, and a communication lab. After curricular revisions, the gerontology course was split into three separate courses (didactics, clinical, and lab) and moved to the second semester. The clinical course was still the nursing student's first exposure to "real" patients.
In an effort to provide student-centered learning, and in conjunction with characteristics of Millennials who want to be involved in decision-making in course development (Weick, 2011), a Course Council, with student representatives from each clinical section, was established to meet with faculty at least monthly to discuss concerns; details are described elsewhere (Heise & Himes, 2010). During council meetings, students' feelings about taking care of older adults were discussed; students spoke of confusion, apprehension, and stress regarding assignments. Based on feedback from students and faculty, course content, both clinical and didactic, was integrated and coordinated with a Fundamentals course taught during the same semester; teaching similar topics often had a reinforcing effect for student learning. A coordinated calendar was established for all courses offered during the semester: Fundamentals, Nursing Care of Older Adults (NCOA), the NCOA clinical component, Communication Lab, and Introduction to Community Health.
Students are more likely to retain knowledge when they are required to use that knowledge in a clinical setting (Benner, Sutphen, Leonard, & Day, 2010). Therefore, faculty worked to coordinate didactic topics with clinical exposure. The intent was not to make the assignments burdensome but, rather, to provide learning activities that centered on what students learned in class. Students are given their assignment during a preconference, prior to the beginning of the shift, and discuss their experiences during the postconference time. (See Table 1.)
In an effort to engage Millennials, a number of activities were designed to allow students to feel, in a small way, what the older adult may be experiencing. These include the "Thought for the Day" (Table 2) at the beginning of class, memory tests, reactiontime tests, sensory kits, polypharmacy kits, and videos showing positive images of aging. Hundreds of student statements on the discussion board, midcourse evaluation, and end-of-semester evaluations demonstrated new perceptions and respect for older adults.
Didactic Activities The following is a more in-depth discussion for selected examples of the assignments.
SENSORY KITS This activity was developed by Dr. Catherine Van Son, Washington State University, School of Nursing. The purpose is to allow students the opportunity to experience, with their senses, some of the changes that happen as people age. Students can experience visual changes by looking through a sandwich bag (two layers = 20/60 vision, four layers = legally blind), as well as changes in touch (wearing gloves and trying to thread a needle and sew on a button) and taste (eat a piece of chocolate while holding nose). (See Innovation Center.)
PILL SORTING ASSIGNMENT DURING POLYPHARMACY LECTURE In this lecture, students are shown a portion of the made-for-TV movie "Where There's a Will." The first few minutes of this movie clearly demonstrate the difficulty encountered in managing medication regimens. Students then complete the pill-sorting assignment developed by Dr. Vickie Johnsen. First, they are each given a bag containing at least 20 "pills," consisting of different sizes, shapes, and brands of candy. They must "sort" their medications according to specific instructions (Table 3). Students are then told they have a particular malady (e.g., a stroke, with loss of ability to use dominant hand; glaucoma; color blindness) and must complete the sorting exercise one more time. In addition, when picking up their bags of medication, students are asked to pay the amount of money owed. These figures are randomly generated and range from $4.00 to $4,000. The point is to help students get a feel for the cost of medications.
LIFE WITH BIG AL When discussing patients with dementia and their caregivers, students are assigned to read this short book (150 pages) by Judy Seegmiller, the widow of a man who suffered from early onset Alzheimer's disease (AD). The book chronicles the author's view of living with "Big Al," who died at age 55 two years after the AD diagnosis. Early in the semester, students discuss the book within their clinical groups; later, during content on caregivers in the didactic portion of the gerontology course, the author visits the class and answers questions about how she dealt with the disease when caring for her husband. (The author has testified before Senate committees on Alzheimer's disease.)
Clinical Activities The following is a more in-depth discussion for selected examples of the assignments.
LIFE HISTORY REFLECTIVE WRITING During clinical in the LTC facility, students choose a patient to interview; they are given a list of suggested questions and conversation starters. After the interview, students write a critical reflective paper about their experience in terms of what they learned, how it affected them personally, and how it will affect their professional career. Frequently, students comment that they were surprised to find that they shared more in common with the senior than they had thought possible. The reflective writing encourages student to put the experience in perspective, personally and professionally.
TRY THIS SERIES RISK SCALES Evidence-based assignments available for students through the Hartford Foundation include general assessments for nutrition, pressure ulcers, depression, and dementia. Additional Try This:® series assessments are discussed throughout the gerontology didactic class, introducing students early in the nursing program to the importance of evidence-based practice and lifelong learning.
WORLD SENIOR GAMES Students in this program are exposed to healthy older adults, at least 50 years of age, through the Huntsman World Senior Games (HWSG) in St. George, Utah. The HWSG attracts approximately 10,000 older adults from around the world to participate in 32 competitive athletic events ranging from Olympic events, like triathlons, to events such as "pickleball." During this experi- ence, students perform health screenings, give flu shots, and are encouraged to watch seniors as they participate in the games. Students typically come away from the activity commenting that seeing active seniors gave them a completely different perspective on aging; they enjoyed the company of participants and are inspired to change their own lives, starting now to be healthy and active.
The Senior Games are held annually only in October; to enhance the winter semester clinical experience, students are given an assignment to identify a person that they view as aging successfully. The student then interviews that person and compares and contrasts (in a written assignment) the healthy senior with the residents they have cared for in the LTC facility.
SIMULATION Students are exposed to other positive geriatric experiences through unfolding, continuing case scenarios in the simulation/skills lab. Using medium- and high-fidelity simulators, students are introduced to a total of five multicultural, elderly "patients" throughout their Fundamentals and medical-surgical courses. These simulated patients are used weekly to reinforce subjects such as oxygenation, elimination, pre- and postsurgical care, and hospitalization. Instructors draw on their stories in the classroom to help situate instruction. As students revisit these patients throughout two semesters, they become very familiar with them as individuals, family members, and citizens. The psychosocial bonds they form with these patients are reported in both midterm and end-ofsemester student evaluations. Students develop a deeper understanding of successful aging as they receive gerontology content simulation experiences throughout the curriculum as well as through the medical-surgical, psychiatric, advanced medical-surgical, community health, and the required global health and human diversity courses.
Implications for Nursing Education The next step for the CON is to conduct a prospective, mixed-model research study to determine the impact of clinical experiences at an LTC facility only versus placements in an LTC facility with two different types of healthy aging assignments (a written assignment vs. participation at senior athletic events) and if that attitude is sustained through four additional semesters in the nursing program. Do perceptions of seniors improve with a combined approach to integrating LTC experiences with healthy aging along with didactic experiences related to older adults?
Society in general needs a paradigm shiftaway from the acute care focus toward preventive care and chronic care selfmanagement. Nurse educators, in particular, have a wealth of resources available and must become leaders in their own schools of nursing to help enlarge the vision, to see older adults as people who can contribute to society through their rich history of experience. (See Sidebar for resources.) We must continue to find innovative ways to engage young nursing students and change their perceptions, so that nursing students will see the benefits of working with older adults. We thus will be able to build capability and capacity to care for older adults.
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About the Authors The authors are faculty at the Brigham Young University College of Nursing, Provo, Utah. Barbara A. Heise, PhD, APRN, BC, assistant professor, teaches introductory gerontology and end-of-life courses. Vickie Johnsen, PhD, RN, is the clinical coordinator for Nursing Care of Older Adults. Deborah Himes, MSN, APRN, BC, is coordinator of the Fundamentals course. Debra Wing, MSN, RN, is assistant coordinator of the Nursing Learning Center and Clinical Simulation Laboratory. Contact Dr. Heise at Barbarafirstname.lastname@example.org for more information.