In this era of accountability and consumer advocacy, the decision-making component of the governance process in schools of nursing is likely to become increasingly complex. The administrative process of establishing rules, decision making, and implementing decisions, referred to as governance,1'2 is influenced by internal and external forces.3 Not the least of these forces are those coming from special interest groups.4'5 While internal and external forces are always operative, force exerted by special interest groups often is relatively minor in the educational institution, until an issue of concern to the general public arises. When the external force is operative, it adds to the complexity of governance, because of increasing numbers of individuals involved in the process of identifying an issue and working toward resolution.
The purpose of this paper is to examine the way an external force may affect the governance process of an educational institution. The activity of a special interest group regarding the issue of inclusion of geriatrics and gerontology training in state supported schools will be used as an example of the influence of an external force on the curriculum.
By exploring some of the circumstances leading to involvement of the special interest group in academic affairs, albeit indirectly, perhaps a perspective may be gained that will be useful in developing collaborative relationships and in achieving goals of mutual interest to nursing education and the general public.
In spite of the increasing number and proportion of the population aged 65 years and above, there has been a dearth of educational programs in gerontological nursing.8'9 This situation has created a problem of unmet needs of the consumer public that is being compounded by the lack of nurses prepared in the field of gerontological nursing, by the lack of opportunity for students to adequately prepare for discharging their responsibility to the aging as professional nurses, and by the increasing number of older Americans concerned for their right to health-illness care.
Although, at first glance, the situation looks negative with respect to the nursing profession, there is evidence of its concern and effort to deal with the unmet societal need for care of the elderly. For example, the establishment of a Division of Geriatric Nursing by the American Nurses' Association (1966) and the Standards of Geriatric Nursing Practice (the title of the Division has since been changed to Gerontological Nursing with a corresponding change in the title of the Standards),10 designed to promote quality care to older persons. Moreover, there is evidence of concern with the need for educational programs that would prepare students for assuming roles in the field of gerontological nursing.11-14
Given these circumstances, how is it that the nursing profession generally, and schools of nursing specifically, have been unequal to accomplishing the task of preparing sufficient numbers of gerontological nurses? Some of the factors that may have hindered more rapid development of programs in gerontological nursing will be cited in the following paragraphs.
For example, Moses and Lake" indicated that a major problem in offering geriatric nursing courses was the attitude of the faculty members. Steffi also cited the negative attitude toward aging in nursing.15 Is it possible that faculty members have reflected the negative attitude toward aging held by the society of which they are a part? Is it possible that faculty members themselves have had inadequate preparation for caring for the elderly that, in turn, affects their attitude toward teaching gerontological nursing?16
Hart et al,17 cited the challenge of nursing education to educate students who would be interested in working with the aged and who would do so with "realistic, supportive and positive attitudes." They noted that there were programs emphasizing the need to increase the knowledge base of students, but that these courses offered little opportunity for personal contact with older persons. They also commented on the need for study of the impact of a learning situation affording opportunity for sustained student contact with several older persons. On the basis of these observations, it would appear that curricular decisions regarding gerontological nursing might be hindered by the lack of programs with clinical experience and the lack of research.
Ornstein18 reported that while nursing schools were attempting to broaden the scope of clinical experiences to include the elderly patient, the student "views geriatric care as negative and one-sided." This view, according to Ornstein, stems from an "inordinate curriculum focus upon in-hospital services" with limited exposure to the area of gerontology. He indicated that emphasis upon degenerative processes of aging has "created some of the problems which beset the field of geriatric nursing today." In this situation, it seems that another factor affecting curricular decisions about gerontological nursing is the use of a more traditional approach to care, based upon the acute care model, rather than upon the health-illness model appropriate to care of older persons with chronic conditions, who may be maintained in their own homes. This approach may be reinforcing the negative stereotype of the elderly as old, sick, and poor. It may decrease the number of students interested in courses on care of the elderly that, in turn, affects administrative decisions about offering such courses.
On the other hand, Gunter12 found that fewer students expressed a strong interest in working with the aged, upon completion of a course in normal development in later life, than was the case in the beginning. More of the students admitted they would avoid working with older patients and in settings serving only older patients. While there may have been other factors operating that contributed to the student reaction, this finding may also be reflective of the societal attitude toward aging. Whatever the reasons for the finding, there is the possibility that it has slowed the development of gerontological nursing programs.
Other problems related to governance in the school of nursing may arise out of conflicting demands on resources needed by the various faculty groups within the school, eg, pediatric, medical-surgical, community health. Budgetary allotment, space allocation, and faculty recruitment are matters of concern to faculty and administration. If the issue of adding another curricular component arises, it may not be favorably received because of limitations thought to exist for the curriculum already in effect.
There is a possibility of resistance to inclusion of gerontological nursing in the curriculum, because of philosophical differences related to the question of whether or not there should be another specialty area. 19 Although there is general acceptance of the specialty area of pediatric nursing, some nurses may feel that care of the adult is being taught, choosing not to accept the concept of differences between the adult and older adult population with respect to health-illness needs and problems.
In addition to philosophical differences about gerontological nursing and the curriculum, resistance to change may also influence decision-making.20'21 Whatever the basis for anxiety related to participating in change, this concern must be acknowledged when considering change, whether it is a single change or multiple changes.
Regardless of the feeling of faculty about change, the fact of change is inescapable. If forces internal to the nursing profession and the educational institution do not effect change in keeping with societal needs and trends, forces external to the profession and educational institution are likely to exert pressure for change.2 This is illustrated by the action of the Kansas Coalition of Aging that was effective in introducing the resolution passed by the legislature (1979) to encourage the inclusion of content on geriatrics and gerontology in the curriculum of state supported schools.23 Already, persons given the responsibility for monitoring the response to the resolution, have begun to raise questions about such content in the curriculum of state schools. Thus, whether or not schools have content on geriatrics and gerontology in the curriculum, there is increasing awareness of the effect of an external force in bringing about change.
For schools needing to tool up for curricular change through the addition of courses on aging, the independent study strategy may be useful. While this approach has been considered an honors program or a part of continuing education by some, it may be effective in the more traditional education programs.24'25 This methodology affords a means for the student to study an area of interest beyond those regularly scheduled courses and, perhaps, an indepth study of the selected content area. Moreover, it can be a means of offering content on geriatrics and gerontology with minimal expenditure, while the process of curricular change is being worked out on a larger scale.
Gerontological nursing and the curriculum have become issues that are likely to increase the complexity of governance in schools of nursing. This potential for increasing complexity of governance arises, in part, out of pressure exerted by an external force outside the school of nursing. The activity of the Kansas Coalition on Aging is an example. The Coalition was successful in getting a resolution passed by the legislature for encouraging inclusion of geriatric and gerontology content in the curriculum of state supported schools. Persons appointed to monitor the response to the resolution have already begun inquiries, raising the consciousness of faculty members. Although in some cases, such content may have already integrated into the curriculum, it is likely that this content will have to be made clearly visible to the individuals doing the monitoring. Thus, because of the involvement of special interest groups outside the school of nursing, the governance process is likely to become more complex. This complexity, however, may bring about a coalition of external and internal forces that will enable schools of nursing to more fully discharge responsibility and accountability to the society that sustains them.
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- 5. Steiman B: Regional Representative, Area VI, AARP/NRTA: Personal communication, May 5, 1978.
- 6. Kansas Coalition on Aging. A group of citizens actively concerned with issues related to the elderly.
- 7. Facts about older Americans 1978: US Department of Health, Education and Welfare, Office of Human Development Services, Administration on Aging, National Clearing House on Aging, Pub No (OHD5) 79-20006.
- 8. Programs that award a masters degree in nursing: American Nurses' Association, Kansas City, Missouri, 1975.
- 9. US Congress, Senate Subcommittee on Long-Term Care, Supporting paper No 4 p X.
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- 23. Senate Concurrent Resolution No 1622, passed by the Kansas Legislature. 1979. Legis Re No 14:7, 1979.
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