As the complex problems of the A aged become key social issues in Contemporary American life, the importance of the field of gerontology is becoming widely recognized. Large groups of people are living to advanced ages, and are simultaneously expressing a multiplicity of needs that have never been faced by society. In the United States today, there are approximately 21 million people 65 or older. In this group, some seven million are over 75 and about one million are over 85. Unfortunately, our aged are discovering that the nation's medical and social institutions are inadequately prepared to meet the unique challenges presented by an enlarged geriatric population.
Currently about 5% of the older Americans reside in institutions, and, for every older person in an institute, there are at least two others who are homebound (one of four of whom are bedridden). It has also been estimated that about one out of five elderly, or 20%, require ongoing chronic care. Further, in succeeding decades, as the oldest of our elderly become a larger percentage, more health services will be necessary.
The situation is further complicated by certain negative attitudes toward aging that have penetrated our national psyche. Many times these attitudes surface among those who must help the aged in the professional setting. Consequently, many senior adults become lost in a dehumanizing treatment syndrome. Hospitals, nursing homes, and social service agencies are slow to integrate a geriatric expertise and a sensitivity to the realities of the aged into the basic processes of their services.
Dade County (Florida), with an elderly population comprising nearly 24% of the total, plays no exception to this problem. Institutions providing services to the elderly have not integrated inservice educational programs directed towards meeting the total needs of the individuals receiving care. This includes physical, mental, emotional, spiritual, and social needs. The paraprofessional schools of nursing have not yet incorporated a meaningful geriatric syllabus in their curriculum.
Nursing home care has been reported as the worst offender in comparisons of care versus cost. Last year more than one quarter of the annual expenditures for health care were utilized by the elderly. This group spent twice as much for health services as the rest of the population combined. Despite these massive expenditures, however, most elderly did not receive quality care. In fact, the cost of medical care for the elderly is disproportionate to the quality of care given within the existing health delivery system. A recent Department of Health, Education, and Welfare task force study contended that poor care in the nursing homes was caused in part by the reliance on untrained and unlicensed personnel. Of the 700,000+ registered nurses in this nation, only 35,000 are employed in nursing homes. From 80-90% of the care is provided by some 215,000 nurse assistants and orderlies with a turnover rate of 75% a year. Within Dade County there are 2,944 licensed practical nurses, of which only about 350 are working in the nursing home.
The elderly in Dade County constitute nearly 24% of the total county population. It is estimated this will increase to over 70% by the year 2,000. There are approximately 37 nursing homes with 5,327 beds and about 30 Home Health Agencies in Dade County. There are over 3,000 nurse assistants currently working within the Dade County health care setting. Most of these individuals must have considerable contact with the geriatric patient during the course of the day, yet do not have any training in the psychological or physical problems of this group. A possible solution for filling this gap might be continuing education.
Meeting The Needs
Douglas Gardens Gerontological Institute of The Miami Jewish Home and Hospital for the Aged, in an attempt to meet the dire community need, applied for and received the Nursing Special Project Grant from the Department of Health, Education, and Welfare to provide training programs for all health care facilities within Dade County.
This program was designed to provide staff development programs in keeping with the personnel needs and the institutional goals. Specifically, the training programs are designed to upgrade the skills of the paraprofessionals, emphasizing the special problems of the geriatric patient. More specifically, it was an attempt to assist the employee to gain knowledge in some areas; to improve performance in specific activities; to perform a new skill and/or improve an existing one; to acquire knowledge that will contribute to personal development and benefit the agency, and to improve interpersonal competencies.
The project was planned to be accomplished while utilizing the four critical assumptions of the adult as a learner. The adult sees himself as essentially self-directing. He comes to the learning situation with living experience and tends to be more settled in his ways and possibly closed to new concepts. The adult is motivated to come into learning by experiencing problems in life that he thinks may be able to be solved by education. Finally, the adult develops a readiness to learn as a result of the developmental requirements of his various roles.
Our goals were the provision of staff development for nursing service personnel and the provision of a framework for research and evaluation of the staff development process and other activities. Unless the nursing department is a learning atmosphere for all levels of nursing personnel, and unless skills are constantly refined by continued appraisal and consequent revision, the highest quality of life for patients cannot be maintained. We further contend that education promotes effective utilization of both professional and paraprofessional staff, fosters good personnel policies, and develops resourceful nurses and assistants who recognize and accept their responsibilities to patients, to the institution, to the community, and to their profession. Information equals quality care.
In an attempt to implement the foregoing grant, onsite visits were made to nursing homes in Dade County to ascertain their needs and seek their cooperation. We interviewed directors of nursing and administrators. We were astonished to hear requests for classes in basic care (eg, baths, bedmaking, etc)- this for nursing assistants who had been employed in the facility for one to ten years! Of those facilities visited 75% indicated attitudinal training and infection control as instructional priorities for nursing assistants. For licensed practical nurses, leadership and documentation were the priorities for 80%. For nursing assistants, we believed the most practical approach would be onsite teaching, targeting all three shifts.
Rather than fragment our efforts, we planned to concentrate on four facilities within an eight-week period-six classes, (one hour each session) per facility per week involving all three shift personnel. We targeted our attention first to nursing assistants. Prior to this, only minimal and scattered attempts to provide inservice for nursing assistants in Dade County Nursing Homes were evident. Of the total number facilities visited, only 13% had an inservice position.
Our program modules for nursing assistants were aimed at providing the participants with an overall awareness and understanding of the geriatric patient and an attainment of a feeling of self-worth and personal growth. It was also felt that if the nursing assistants understood the rationale ("whys and wherefores"), it would enable them to give more comprehensive, better quality care.
Based on the education needs assessment, the course syllabus for "The Aging Process" was developed to include two instructional units:
1. Introduction and physiological background for the aging process; and
2. Physical and psychosocial problems involved with aging, including nursing implications.
Unit 1 began with cell structure and was developed with, necessarily brief, discussions of the anatomy and physiology of the human body. With each body system described, the normal changes in aging were discussed. In the instructional packets given to each participant, relevant diagrams and handouts were presented. For example: in discussing the integumentary system, with the physiology of the skin, information was disseminated on body odors, skin care, and infection control (eg, hand washing).
Unit 2 detailed various physical and mental disabilities encountered in the institutionalized elderly. Problem areas explained included stroke, diabetes, depression/confusion/senile dementia, dehydration, decubiti, sexuality, death, and dying. Appropriate handouts were given for each lesson. Some examples are: a range-of-motion booklet, diagram of how diabetes occurs, diabetic foot care, diabetic complications, simple guidelines for reality orientation, and others pertinent to each lesson.
In order to encourage participation, classes were conducted within the working environs of the participant and no attempt was made to grade the participants, thus removing the threat of failure. Preand post-testing of cognitive knowledge (instructor-developed) was used for statistical data. Deliberately, both instructors tried to maintain a low-keyed, informal atmosphere to stimulate participation. During the course of the training sessions, it was found that the majority of the nursing assistants were most receptive to learning. After gainingconfidertce in the instructors, a rapport was established and they verbalized freely knowing they would receive confidentiality.
Some of the problems frequently expressed were:
1. Lack of handwashing between patients due to lack of adjacent facilities and/or supplies;
2. Nurses ignoring nurse aides when they report a patient fall and needed dressing changes;
3. Patients dressed in clean clothing at 7 AM and still wearing the same clothes that night at 11 PM;
4. Lack of information required to give adequate care to patients-no change of shift reports;
5. Unable to look at patient care plans;
6. Personal stresses felt in accomplishing their work load and managing the confused (wandering) patient;
7. Nurses do not make walking rounds; and
8. Nurses, for the most part, do no physical care for residents.
There were many variables in the teaching/learning milieu:
1. Lateness-unable to leave unit on time;
2. Leaving class early-to get public transportation;
3. Noise levels-poor temperature control;
4. Last minute changes of classroom;
5. Lack of interest on the part of superiors;
6. Lack of follow-up and reinforcement by superiors;
7. Lack of continuity (students unable to attend each session);
8. Little or no pre-existing inservice education; and
9. Instructor stress-classes were given in the morning for 7-3 personnel, in the afternoon for 3-11, and sometime after midnight for 11-7. This was done to maintain continuity. In addition, many of the participants expressed their feeling that their administrators and directors of nursing place a very low value on their nursing assistants, demonstrated by minimal wages, lack of recognition, and little or no communications.
A questionnaire was completed by each participant at the first class session to provide additional information relative to individual training needs, perceptions of the elderly, and problems in care giving. An overview of the results is of interest:
- 66% of the trainees received their training in a school setting-the average training program was six months;
- 55% indicated that involvement in care of the elderly was a personal choice, rather than a function of job availability;
- 40% identified the need for additional training in "physical care of the elderly";
- 64% felt ill-equipped to discuss death and dying;
- 49% indicated that patience is the most important personal quality to enable the delivery of excellent care; and
- 66% participated in no inservice program in the last year.
Pre- and post-testing demonstrated an increase in cognitive knowledge. One question relating to the normal aging process had two correct response choices:
a. "Blood vessels are less elastic"-correct responses: pretest 39% and posttest 55%.
b. "Sight and hearing are impaired"-correct responses: pretest 57% and posttest 70%.
Another question dealing with the average human being's sexual needs or desires after the age of 60, showed a positive increase of 18% in knowledge and/or attitudes.
Three-month, follow-up surveys were requested of the directors of nursing and administrators of the facilities involved. A 50% response indicated that there were some improvements in job performance and positive changes in attitudes toward residents and other staff members.
Our educational approach to licensed practical nurse personnel was in a different vein. After numerous requests from area facilities, we applied for and received a provider number for Continuing Education Units for nurses. Aware of the realities of the situation in area nursing homes (licensed practical nurses function as charge nurses with no preparation), our first training session addressed the topic of leadership and management. To permit group interaction, six, daylong programs were held, limiting enrollment to 25 persons each session. The participants represented 33 area nursing homes and hospitals. A pretraining questionnaire demonstrated that 59% felt that their management skills and training were greatly deficient. Sixty percent indicated that they received little administrative support in the role of charge nurse. This data was further substantiated during group interaction.
This program addressed the following topics in great detail:
1. Management theories and styles;
2. Personal qualities needed for leadership;
3. Role of the licensed practical nurse as a manager;
4. Universal requirements of all managers/leaders;
5. Nursing process/problem solving/quality care; and
6. Documentation-patient care plan, charting, and nursing audit.
The next programing for licensed practical nurses involved two, daylong sessions on the physical and psychosocial aspects of aging. Participants represented 31 nursing homes and five hospitals in Dade County. Pre- and post-testing utilized was a basic knowledge of aging quiz. Tabulated results showed a 75% gain in cognitive knowledge.
For all programs, pertinent handouts were given to participants to enable them to relay information to other staff members in their individual facilities. It is of interest to note that, following their return to their organizations and giving their own inservice programs using our materials, we were besieged with calls for further programs from area licensed practical and registered nurses.
Within this same time frame, we were requested to speak on changes in aging and quality care at several area hospitals, Florida Nurses Association, Florida International University, Outreach Workers, Barry College social work students, and Nursing Home Ombudsman Committee, Districts X and XI (of which each of us is a volunteer member within the county in which we reside).
No educational program is a panacea, per se, for all the ills o£ society. However, evaluation measures are guidelines for observable behavioral changes. We utilized Our own evaluative tools in assessing the participants. We also requested evaluation of participant behavioral changes from administrators and directors of nursing. It is hoped that whatever changes we may be able to promote will be further observed and encouraged by the facility management. Education is valueless unless there is a continuation and follow-up of the precepts offered. We can onLy malee a small beginning-the balance of the benefits to be reaped are dependent upon the attitudes, communications, and interpersonal relationships fostered by those in management.
Throughout each program offered, it came to our attention that further educational input is desirable for the professional nurse as well. We have requested permission to include this level in our teaching plans. To promote motivation and continuity in upgrading the level of care of the elderly, each area in nursing must be impressed with the primary goal for all of us-improving care for the patient!
Finally, we would be most willing to share our program formats with interested parties to foster our goal of high quality of care for our aged clientele.
This project was supported by Grant # 1 DIO NU 24035-01, a Nursing Special Project Grant awarded by the Department of Health, Education and Welfare.