Journal of Gerontological Nursing

Effect of a Course on Aging in a Graduate Nursing Curriculum: A Small Descriptive Study

June Hannon

Abstract

To meet the challenge of providing quality care to the growing population of elderly citizens, nursing educators must face their responsibilities. A search of the literature relative to geriatric content in undergraduate nursing programs reveals that, traditionally, curriculum patterns have not responded to the needs of the aged. A survey of 138 schools of nursing1 disclosed that 13% had courses in geriatric nursing, 9% of which listed courses with titles reflecting geriatric content. The report recommended "that creative approaches toward motivating students to see the challenge of geriatric care" be investigated. Fennessey2 stated that the usual pattern includes a unit on the care of the aging in an integrated sophomore course. Discussion in the other two articles makes reference to a frequent practice by fundamental nursing instructors of mistakenly using nursing homes as clinical facilities to learn basic nursing skills and unintentionally contributing to "the rape of a sound geriatric program."3,4 To develop positive attitudes toward the aged, each student should first be exposed to the relatively well client in the community and to the normal physiological and psychological process of aging.

In 1976, Raheja and Beniger5 suggested that a sequence of courses on normal growth and development throughout the life span be required during the freshman and sophomore years "because this is the time when a philosophy of nursing is formulated." They further state that until nurses integrate the concepts and dynamics of aging into their theory and practice, "they cannot provide therapeutic nursing care of the older adult."

Although there have been references made to the need for laying the foundation in gerontological nursing early in the curriculum (sophomore year), a recent curriculum guide developed for incorporating gerontology into a baccalaureate nursing curriculum provides for gerontology content to begin with the sophomore year and continue through the junior and senior years.6

Another factor noted by Moses and Lake1 as a major deterrent to offering geriatric nursing content in undergraduate programs was found to be in the attitude of faculty members themselves that the care of the aged is depressing and lacking in reward. Masters programs are needed to prepare nurse educators in geriatric nursing.

The curriculum design of the masters program at Louisiana State University Medical Center permits students to choose a specialization in either adult health and illness of psychiatric/community mental health and a functional area in either nursing service delivery or education. One of the assumptions used as a guideline for the structure of graduate-level preparation in the study of aging was that the courses be developed from a multidisciplinary perspective. To effect this the graduate course, Study of Aging, was undertaken with collaboration between nursing faculty and other university faculty with research interests in aging.

Further guidelines for courses in the graduate curriculum in geriatric nursing education detailed by Gunter and Estes7 emphasize activities that require: interpretation and/or synthesis of information; analysis of data as a basis for drawing conclusions; formulation of hypothesis, theories, and experiments or projects; uses of concepts and principles to solve new problems; and evaluation and/or critique of studies. These effective methods of bringing together national planning and human orientation are what graduate education is all about.

Learning experiences for students were varied. Selected topics of interest were chosen by students for a written report and presentation in an individually led seminar. In addition special projects were required. Each student individually initiated contact with a previously unknown elderly person to develop a relationship in which the student had the opportunity of exploring the meaning of aging with a particular "well" older person. The visits of each student numbered at least four…

To meet the challenge of providing quality care to the growing population of elderly citizens, nursing educators must face their responsibilities. A search of the literature relative to geriatric content in undergraduate nursing programs reveals that, traditionally, curriculum patterns have not responded to the needs of the aged. A survey of 138 schools of nursing1 disclosed that 13% had courses in geriatric nursing, 9% of which listed courses with titles reflecting geriatric content. The report recommended "that creative approaches toward motivating students to see the challenge of geriatric care" be investigated. Fennessey2 stated that the usual pattern includes a unit on the care of the aging in an integrated sophomore course. Discussion in the other two articles makes reference to a frequent practice by fundamental nursing instructors of mistakenly using nursing homes as clinical facilities to learn basic nursing skills and unintentionally contributing to "the rape of a sound geriatric program."3,4 To develop positive attitudes toward the aged, each student should first be exposed to the relatively well client in the community and to the normal physiological and psychological process of aging.

In 1976, Raheja and Beniger5 suggested that a sequence of courses on normal growth and development throughout the life span be required during the freshman and sophomore years "because this is the time when a philosophy of nursing is formulated." They further state that until nurses integrate the concepts and dynamics of aging into their theory and practice, "they cannot provide therapeutic nursing care of the older adult."

Although there have been references made to the need for laying the foundation in gerontological nursing early in the curriculum (sophomore year), a recent curriculum guide developed for incorporating gerontology into a baccalaureate nursing curriculum provides for gerontology content to begin with the sophomore year and continue through the junior and senior years.6

Another factor noted by Moses and Lake1 as a major deterrent to offering geriatric nursing content in undergraduate programs was found to be in the attitude of faculty members themselves that the care of the aged is depressing and lacking in reward. Masters programs are needed to prepare nurse educators in geriatric nursing.

The curriculum design of the masters program at Louisiana State University Medical Center permits students to choose a specialization in either adult health and illness of psychiatric/community mental health and a functional area in either nursing service delivery or education. One of the assumptions used as a guideline for the structure of graduate-level preparation in the study of aging was that the courses be developed from a multidisciplinary perspective. To effect this the graduate course, Study of Aging, was undertaken with collaboration between nursing faculty and other university faculty with research interests in aging.

Further guidelines for courses in the graduate curriculum in geriatric nursing education detailed by Gunter and Estes7 emphasize activities that require: interpretation and/or synthesis of information; analysis of data as a basis for drawing conclusions; formulation of hypothesis, theories, and experiments or projects; uses of concepts and principles to solve new problems; and evaluation and/or critique of studies. These effective methods of bringing together national planning and human orientation are what graduate education is all about.

Learning experiences for students were varied. Selected topics of interest were chosen by students for a written report and presentation in an individually led seminar. In addition special projects were required. Each student individually initiated contact with a previously unknown elderly person to develop a relationship in which the student had the opportunity of exploring the meaning of aging with a particular "well" older person. The visits of each student numbered at least four and were recorded in a log submitted periodically to the instructor. Students had the freedom to select their own format for the interviews. However, special guidelines were given for termination of the interview experience to minimize the feelings engendered by the separation for both students and the aged persons. Although the interview experience was of short duration, it was believed that the relationship between the student and the aged person had meaning and special thought should be given to terminating the experience. In some situations the student may have become a valuable source of relief from loneliness, isolation, and boredom for the aging person and the separation would represent a loss. Students were requested to summarize their interview experience and express what meaning the experience had for them.

To further assist students in evaluating the quality of the lives of the aged and in gaining insight into the attitudes of the aging, a second project was an assignment to analyze aging as portrayed by a character in a work of fiction. A written guide was provided to students for this activity with suggested questions for consideration in their analysis of the fictional character's successful or unsuccessful life from multiple standpoints; eg, personal integrity, position in society, family relationships, losses, etc. Students also submitted a brief statement of their beliefs and feelings about their own aging.

One tool selected to measure change in the information level was Palmore's8 "Facts on Aging: A Short Quiz," which was designed to focus upon basic physical, mental, and social facts as well as common misconceptions about aging. As noted by Palmore, his instrument was designed as an improvement upon several previous scales and tests on aging. It is short; factual statements are documented; and factual statements are not confused with attitudinal statements. One of the recommended uses is "to measure the effects of lectures, courses or other training experiences by comparing before and after scores" which was the primary reason for its selection in this study."

A comparison of incorrect responses before and after the course indicated that students' level of information increased. A mean score for items scored incorrectly before the course was 8.1 with a standard deviation of 2.3; postcourse, 5.5 with 1.5 standard deviation. Table I shows an increase in percentage of errors on four items. One item worded: "In general, most old people are pretty much alike"8 (Item No. 15, Table I), was correctly marked by all students before, but incorrectly marked by one student after. From the conduct of the course there is no explanation for the student's error. One item on which all students were in error concerned the current percentage of the aged population in the United States. Apparently the information given students in the course was in conflict with that documented in the quiz. This conflict was also evident to the instructor ort the items that old people take longer to learn something new and the increase in religiousness of old people (Item Nos. 12 and 23, Table Í). Other uses of the quiz offered an indirect measure of bias, both positive and negative, toward the aged and a means of identifying students' misconceptions about aging.

Some of the frequent misconceptions about aging, particularly negative stereotypes, that exaggerate the problems of the aged were evident at the beginning of the course by the responses illustrated in Table I. A high percentage (80%) believed that a large proportion of the aged live in institutions (70%). Other misconceptions held by the students at the beginning of the class were that a majority of the aged are frequently bored (70%, Item No. 16); that the majority of old people are seldom irritated or angry (70%, Item No. 24); and that the majority of the aged have incomes below the official proverty level (90%, Item No. 21). Comparison with the posttest shows only half or less of the students held these negative stereotypes after the course.

Table

TABLE ISTUDENT ERRORS ON SELECTED STATEMENTS FROM PALMORE'S FACTS ON AGING QUIZ8 PRE- AND POST-COURSE, "STUDY OF AGING"

TABLE I

STUDENT ERRORS ON SELECTED STATEMENTS FROM PALMORE'S FACTS ON AGING QUIZ8 PRE- AND POST-COURSE, "STUDY OF AGING"

Upon examination of the content, the increase of incorrect responses is unexplainable in all three instances. Relative to Item No. 12, the postresponse changed from an even division between negative and positive to an increase by one in favor of the fact that old people do not usually take longer to learn something new. Item No. 15, which stated that most old people are pretty much alike, was correctly scored by all students as false in the pretest but received one mark of true in the posttest, indicating positive bias. Conversely, there was an increase by 20% in the negative bias in regard to Item No. 22, which indicated that the majority of old people are working or would like to have work to do. Two additional items (Nos. 16 and 24) intended to be scored as true, although reduced in percentage of error, still retained an unexplainable number of incorrect responses. These items stated that the majority of old people are "seldom bored" and "irritated and angry."

Table II shows the pro- and antibias of students pre- and postcourse. Students tended to have more antiaged errors than proaged errors; however, students had less pro- and anti-aged errors following the course. Examination of the incorrectly marked items indicate a positive bias on the item stating that all five senses tend to decline in old age. After the course all students gave a correct response. A second item showing a positive bias on the pretest stated that older people usually take longer to learn something new. Positive bias on this item was not reduced on the posttest. Looking at the net bias scores for individual subjects (Table III), revealed that three students who had proaged bias precourse hadantibias postcourse; that three students retained a negative net bias; that one student with proage bias retained this probias; and that three students changed their antiaged bias to proaged bias.

Table

TABLE IIPRO- AND ANTI-AGED ERRORS IN KOGAN'S ATTITUDE SCALE PRE- AND POST-COURSE, "STUDY OF AGING"TABLE IIIDEGREE OF AGREEMENT OR DISAGREEMENT ON POSITIVE AND NEGATIVE STATEMENTS (KOGAN'S ATTITUDE SCALER PRE- AND POST-COURSE, "STUDY OF AGING"

TABLE II

PRO- AND ANTI-AGED ERRORS IN KOGAN'S ATTITUDE SCALE PRE- AND POST-COURSE, "STUDY OF AGING"

TABLE III

DEGREE OF AGREEMENT OR DISAGREEMENT ON POSITIVE AND NEGATIVE STATEMENTS (KOGAN'S ATTITUDE SCALER PRE- AND POST-COURSE, "STUDY OF AGING"

A second instrument, Kogan's Attitudes Toward Old People,9 was selected to assess students' attitudes toward old people. The scales were administered pre- and post-course. Half of the items expressed negative sentiments about old people, the remainder of the items were constructed to reflect the positive opposite. A comparison of the degree of response (agreement or disagreement) on negative and positive items was made between the pretest and posttest.

A score was assigned to six values: slightly agree, agree, strongly agree, slightly disagree, disagree, and strongly disagree, individual scores added per item. Table III shows an increase after the course in the mean score on both responses of disagreement with negative statements (-) and agreement with positive statements (+). Apparently, a majority of the students responded more intensely following their learning experiences in the course.

A pattern of contradiction between the pre- and post-tests was established by pairing the negative and positive statements. The items on which students were,most inconsistant numbered two; one, negative, and one, positive. The negative item stated "most old people bore others by their insistence on talking about 'good old days'."9 Six students gave incongruent responses; three changed from disagree to agree; three, from agree to disagree. However, in contradiction, the positive counterpart that stated "one of the most interesting qualities of old people is their accounts of their past experiences"9 received 100% agreement on both the pre- and the posttest. Students were inconsistent in response to the positive statement concerning the residential aspects of old person's lives, "You can count on finding a nice neighborhood when there is a sizeable number of old people living in it."9 In the pretest five students agreed with the item; in the posttest, eight students. The negative statement, "In order to maintain a nice residential neighborhood, it would be best if too many old people did not live in it,"9 on the pretest received a response of 100% disagreement; on the posttest, 90%.

Two items reflecting "the degree to which vague feelings of discomfort and tension are experienced in the company of old people"9 received consistent responses by all students, an indication, perhaps, that the respondents were comfortable in interpersonal relationships with older persons. This is attributable, in part, to the fact that students in nursing, particularly at the graduate level, have had more experiences in relating to the aged.

From the instructor's viewpoint, an analysis of students' written assignments and validated by students' evaluation remarks indicated that the relationship experience with an older person, the fictional analysis of aging, and the personal paper on aging contributed significant learning that brought emphasis to the psychological factors of aging. The instructor was impressed with the revealing sensitivity of the students' personal statements.10 Two categories were used in examining the personal papers: one- hopes for old age; and two-fears of old age.

The overwhelming theme underlying "hope" for students' aging was independence, until such time as loss of physical or mental capacity would require dependence upon loved ones. Most students expressed an expectation that the extended family would provide a continued relationship and supply security, warmth, and companionship. Many students explicitly stated they wanted to experience aging with courage, grace, dignity, respect, and flexibility. The desire to be active, continue to be a contributing citizen, and grow and learn were also prime concerns. Nursing was mentioned by several students as an "excellent field to grow old and mature in" with its "opportunity to meet people, exchange ideas, and feelings" and experience "a sense of personal satisfaction of helping another." Other wishes in looking forward to old age were: "to retain enthusiasm to enjoy life"; "to have more time for things I like to do for fun"; "to know the security of experience and knowledge that comes with age"; "to experience the pleasures of watching their child (or children) mature"; and "to want all the goodies that come with aging."

Fears expressd were in many ways-loneliness and depression; despair for unfilled goals; society's rejection as "being out-of-date and useless; and infirmity and loss of physical capacity. One student stated, "I don't want to watch (life) go by through a bedrail." Most students intellectually acknowledged aging as inevitable and a natural process that they did not fear, yet emotionally they found difficulty in facing (coming to grips with) that it (aging) doesn't just "happen to others." Some students did not mention death or dying; some mentioned religion as a source of strength in thinking about death; some stated that they didn't want to think about it; and some said they had no fear and as nurses they were "familiar with death." Other fears relative to death were being alone and not being prepared; fear of being "cut short" and fear of "being left behind." Thought of death for one student left a "lead lump in my throat."10

Half of the students mentioned loss of physical attractiveness in aging as a fear, with specific mention of dry skin, wrinkles, loss of muscle tone, weight gain, and gray hair as negative factors. One student, however, said that with age there was a "different kind of attractiveness."10

The experience generally was a positive one; one that put them in touch with their feelings and made them "come to grips" with their thoughts about aging. Only one student said the experience was not particularly helpful.

Student interviews were documented and summarized in a journal and analyzed by the instructor. The social theories of aging in particular were applied to the interviewees and in several of the interviews there was a tendency toward the life review process." There was evidence of genuine rapport and involvement in the relationships. The persons interviewed were five females ranging in age from 63 to 92, and five males, 65 to 76. Students devised their own format to develop the relationships through unstructured interviews and a profile of the persons. An attempt was made to capture the words of the interviewees and their view of the world of an aging person. Students showed genuine interest in what the older persons had to say and the students accepted them as persons with whom they looked forward to spending time, not only in interviewing, but some in genuinely sharing their everyday activities.

Students were unanimously enthusiastic about the interview with an older person in relation to its positive effect on their attitude toward aging. In general the conclusion was that fhe experiences with "well" elderly persons improved students' attitudes toward aging.12

This exploratory study on the effect of an introductory course on aging showed an increase in graduate nursing students' factual knowledge and positive changes in their misconceptions and biases toward aging. Other nursing education studies with baccalaureate nursing students have provided the beginning findings that learning experiences, affording personal contacts with the aged and increasing students' knowledge base about aging, improved attitudes toward the aged.13 However, there was concern that improved attitudes about aging do not insure chat students as graduates will choose to work with the elderly.14 *

The study was necessarily limited because of the small sample of ten students. Since additional courses will be developed under the grant, it will be possible to continue the evaluation of the effect of the special courses on the same students of this study plus other students.

In the future a control will be introduced by administering the evaluation instruments of this study to graduate nursing students not enrolled in the gerontology course. In reviewing the specific tools selected for pre- and post-assessment in this study, Kogan's "Old People Scales" presented drawbacks because some of the words in several of the attitudinal statements are unclear. Further study will be needed to evaluate the effect of the nursing behavior of the graduates following completion of the program.

References

  • 1. Moses D, Lake C: Geriatrics in the Baccalaureate Nursing Curriculum. New Orleans, July 1Í968, pp 41-48.
  • 2. Fennessey CM: Nursing care of the aged patient. Hosp Progress 51:46-50, 1970.
  • 3. Chamberland G, Rawls B, Powell C, et al : Improving students' attitudes toward aging. J Gerontol Nurs 4(l):44-45, JanFeb 1979.
  • 4. Roberts MJ, Powell C: The rape of geriatrics by fundamental nursing instructors. J Gerontol Nurs 4(5):35-37, Sepi-Oct 1978.
  • 5. Raheja K, Beniger M: Where is gerontology in the curriculum. J Gerontol Nurs 2(S):8, May-June 1976.
  • 6. Combe L, Leese M, Morgan D: Incorporating gerontology in a nursing curriculum: An instructional system. Unpublished paper, July 1979.
  • 7. Gunter L, Estes C: Education for Gerontic Nursing. New York, Springer Co, Inc. 1979.
  • 8. Palmore E: Facts on aging: A short quiz. Gerontologist 17:315-320, 1977.
  • 9. Kogan N: Attitudes toward old people: The development of a scale and an examination of correlates. J Abnorm Soc Psychol 62:44-54, 1961.
  • 10. Personal statements on aging. Unpublished, Louisiana State University, Graduate Program, Course: The Study of Aging, Fall 1978.
  • 11. Butler R: The life review: An interpretation of reminiscence in the aged. Psychiatry 26(l):65-75, 1965.
  • 12. Hart LK, Freel MI, Crowell CM: Changing attitudes toward the aged and interest in caring for the aged. J Gerontol Nürs 2:10»I6, july-Aug 1976.
  • 13. Gunter L: Student's attitudes toward geriatric nursing. Nurs Outlook 19:466, 1971.
  • 14. Kayser JS, Minnigerode FA: Increasing nursing students' interest in working with aged patients. Nurs Res 24:23, 1975.

TABLE I

STUDENT ERRORS ON SELECTED STATEMENTS FROM PALMORE'S FACTS ON AGING QUIZ8 PRE- AND POST-COURSE, "STUDY OF AGING"

TABLE II

PRO- AND ANTI-AGED ERRORS IN KOGAN'S ATTITUDE SCALE PRE- AND POST-COURSE, "STUDY OF AGING"

TABLE III

DEGREE OF AGREEMENT OR DISAGREEMENT ON POSITIVE AND NEGATIVE STATEMENTS (KOGAN'S ATTITUDE SCALER PRE- AND POST-COURSE, "STUDY OF AGING"

10.3928/0098-9134-19801001-09

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