The elderly are not favorite clientele among health professionals. Yet, as the proportion of those over 65 increases from the current 10% to the expected 30% by the year 2030, so does their need for health care service. In fact, we are told by Galton, in Don't Give Up on the Aging Parent, that people in this age group are recipients of 70% of all prescriptions written.1 Despite this growing need for healthcare services to an expanding elderly clientele, an American Hospital Association survey conducted in 1974 revealed that less than 1% of 11,000 nursing students surveyed preferred geriatrics as a field of nursing practice.2 Ironically, at a time when the nation's birth rate had dropped and population growth was zero, obstetrics far outranked geriatrics as a choice of career. Out of 22 specialties available to the 11,000 graduating nursing students, geriatrics ranked 16th.
I} ndou btedly, n urses avoid caring for geriatric patients for a variety of reasons. There is little professional status for nurses working in nursing homes or other agencies that service the elderly. In contrast to the nursing elite who provide highly specialized care in a daily, dramatic, life-and-death struggle within intensive care units, nurses who care for the debilitated and/or chronically-ill elderly are less respected by their professional peers. The low esteem awarded nurse-caretakers of the elderly is also reflective of the low esteem our society awards to its elderly members. Consequently, nurses who desire to improve their professional status either do not enter the field at all or leave it after a short period of time for more rewarding positions. The turnover rate in nursing homes is estimated to be 60%.3 A pervasive theme in this downgrading and avoidance of geriatrics and the elderly appears to be the negative, stereotyped attitudes toward the. elderly which permeate our society and are shared by nurses.4 Negative attitudes generate avoidance behavior and also act as a barrier to the formation of therapeutic relationships with geriatric patients.5
Several reports in the nursing literature have focused on the use of different educational models to improve the attitude of students toward the elderly. Also, these past studies were built on an assumption that a demonstrated improvement in student attitudes toward well elderly would also apply to their attitude toward sick elderly. This assumption is open to question. In the future, evaluations of educational programs ought to assess their effect on student attitudes toward sick old persons since these may be quite different from attitudes toward the healthy aged.
To date, all of the reportedly successful educational interventions have a common denominator of structured clinical and/or classroom requirements of at least one semester in length.6 None address the need for an innovative teaching method of (1) variable length to address the time availability of nursing personnel who are not a captive audience in a required undergraduate course, or (2) of sufficient magnetism to appeal to those who might tend to avoid a class in geriatric nursing, just as they avoid the elderly themselves. To entice such a target group into an educational experience not only short and attractive but also effective in altering deeply ingrained attitudes and responses to the elderly, I designed a simulation game called Life-Cycle. The game combines, in one educational package, teaching modes previously demonstrated to be powerful in their impact: simulation-gaming, modeling, role-playing of critical incidents, mutual recall of roleplays, and confrontation stimulated by the play-back of video- and audio-tapes of "role-plays, peer learning, and positive and negative reinforcers.
Development of the Game
The game is a product of my sequential background experiences as nursing home staff member, educator, and mental health consultant to staff of nursing homes. During these experiences, I had an opportunity over a long period of time to observe interactions taking place in nursing homes between nursing personnel and patients. In analyzing their interactions, 1 concluded that the negative attitudes and nontherapeutic responses of nurses to the sick elderly was fundamentally related to their lack of understanding for what it is like to be old and sick in our society. Reports in the literature supported what I suspected-that those who lacked a first hand, positive experience of aging from a long-term, reality-based association with an aged relative or friend in both sick and well circumstances are apt to develop stereotyped images of the elderly. In our age segregated society, those who have little or no association with the elderly tend to derive their image of older persons from the skewed, unpleasant examples too often portrayed in the mass media or from their professional contact with a nonrepresentative group of sick, institutionalized old persons. It seemed to me the best way to improve the negative orientation of some nurses toward elderly patients was to provide them with an opportunity to step prematurely into simulated old age where they could act out difficult situations common in the lives of elderly persons. This was the underlying rationale for the simulation game. In its development, other educational elements were incorporated to further enhance the psychological impact of a simulated experience of aging.
Simulation-gaming development is á complex process which, according to John R. Raser,7 contributes to theory building. It requires abstraction from reality of the critical elements of a concept and the prediction of the nature of the relationship between the elements of the concept. In Life-Cycle, the rules of the game and the critical incidents reflect hypothesized interrelationships between role players. The play of the game becomes an experiment in testing those hypotheses, and thereby can serve as a vehicle for testing theory and generating new theory. For this reason, in addition to its value as an educational tool, Life-Cycle, like other simulations, has great potential as a research tool to test theory and collect data in a simulation laboratory.
Why a Game?
Games have characteristics that are especially facilitative of learning, such as their ability to focus attention, their requirement for action rather than merely passive observation, their abstraction of simple elements from the complex confusion of reality, and the intrinsic rewards they hold for mastery. "By the combination of these properties that games provide, they show remarkable consequences as devices for learning," reported Boocock and Schild.8
Defense of games culminates in the work of John Dewey, who claimed that by filling a basic human need for make-believe activity, play, and games motivate the student to become actively involved in the learning process. Dewey's pedagogical philosophy focused on active learning rather than "teaching by pouring it in, learning by passive absorption."9
In a Report on Education Research, the following was reported about simulation games:
* The types of media used in the exercise have an impact on participant performance. If the simulation includes the use of both audio- and visual-media, the performance of participants improves compared to that when only one type of medium is used or none at all.
* By participating in simulation exercises, players may develop more empathy for the roles they are assuming and the complexities of the environment with which they are dealing.
* Repeated use of the exercises seems to improve the performance of the participants.
* Participants appear to develop a better understanding of the system dynamics and respect for the complex interplay of variables in a social system.
* Simulation games affect the attitudes of students who play. In general, "a simulation game can be expected to increase the player's level of tolerance, approval, or empathy for the real-life person whose role the player takes in the game." Emotional arousal during a game (as indicated by fluctuation in the heart rate) is related to changes in attitude, and the emotional arousal of one participant in a game is contagious-if one student gets excited, others will, too.10
Life-Cycle, as a game, appeals to the reluctant learner. The colorful gaming materials pique the curiosity and interest of students. The attraction of the game tends to counteract the normal resistance forces of fear and self-defense which often make role-playing difficult to initiate. Role-playing is thereby accelerated into a more concentrated period of time. In three minutes of role-playing enough material is generated for 30 minutes of postgame discussion and learning. In addition, the spirit of sportsmanship and fun that prevail in a game atmosphere permit spontaneity and laughter, which further helps to relieve the tension normally associated with a risk-taking situation. Boocook and Schild insisted that even students who initially find the game no more appealing than the conventional activity should withdraw less in the game, because they would be drawn into the situation by the other players.8
The rules of Life-Cycle structure the learning process, thereby transferring responsibility for the success of the game from teacher to learner. A throw of the dice and a move of the player's token around the game board selects the role a player is to play. Critical incident cards, supplied to the players by the game manager, program the two role players into approaching a situation with conflicting perspectives that provide material for a meaningful dialogue. Since the game manager is seen as a facilitator rather than a judging authority, the player's desire to change a habitual response is experienced as coming from within rather than being imposed by some outside authority. With the teacher removed from the expert role, participants turn to each other for less threatening feedback. In such a mutually supportive atmosphere students feel that they can safely test out alternative responses, analyze the effects of their words upon the other party in a detached manner and make mistakes without having to pay the real-life consequences. Whereas the teacher acts as a game manager, role players are the actors, and peers are the directors who encourage more effective methods of script delivery or even suggest script changes to affect more therapeutic responses to the elderly person in distress.
Games also have a built-in reward system. In Life-Cycle, role players make a special effort to perform well and authentically avoid receiving negative reinforcers from their peers in the form of "cop-out" tokens. Significant others who interact with the elderly receive blue or red poker chip rewards, depending upon the postive or negative feelings they induce in the old person and the therapeutic quality of their communication.
In any game, players enjoy the challenge of continually improving their performance. In Life-Cycle, the critical situations can be replayed countless times by different players, depending upon the toss of the dice. Each performance is an effort to improve over the last. The variations on the theme are endless, with each variation producing new material for learning.
In a nutshell, the enticement of the gaming modality, peer pressure, and the rules of the game engage individuals who might otherwise resist a learning experience in the process of producing realistic roleplays. Once engaged, players and observers develop more empathy for the feelings and motivations of the elderly. In a safe, make-believe gaming atmosphere they are apt to take risks and try out new behaviors in order to discover the most effective method of responding to the elderly in similar situations. When audio- and visual-media is incorporated into the game process, the learning is further enhanced.
Who Can Play?
Nurses, medical students, physicians, nursing home administrators, nurses' aides, music therapists, chaplains, pharmacists, gerontologists, volunteer workers, dieticians, and housekeepers have played LifeCycle. In fact, an interdisciplinary group of players is preferable because it adds another learning dimension. When members of different disciplines observe each other handle difficult encounters, they each develop a greater appreciation for the unique contribution their teammates make in caring for the elderly. When participants are an interdisciplinary team of co-workers, they usually become more cohesive because they engage in joint problem solving, which often carries over into the work situation. Many participants playing LifeCycle with co-workers have commented, "We need to problem solve like this together at work more often in the future."
How Do You Play the Game?
The number of role players is usually limited to six or eight at a time, but the observers, who become active participants in the postgame analysis, can number up to 20. It is possible to use Life-Cycle with larger groups, but the degree of active participation decreases as the class size increases.
An instruction booklet and videotape, or slide/tape demonstration, which are part of the teaching package, describe the rules of the game and the gaming process in detail. The rules are also summarized and published in the supplement 1977 issue of Health Education Monographs."
Evaluation of the Game
The effectiveness of Life-Cycle as an educational tool was evaluated in a 100-bed private nursing home in a Michigan suburb. The sample consisted of 33 females and one male randomly selected from the nursing home personnel and assigned to experimental and control groups. All of the subjects reported they had had no formal training in the field of geriatrics.
One week after completion of an 11-hour training program using Life-Cycle, the subjects in both groups gathered in a meeting room to view a three-minute, critical incident, stimulus videotape of a professional actor portraying a distressed, sick elderly gentleman speaking directly to the audience about his feelings of rejection and despondency at being left in a nursing home by his son against his wishes. After viewing the tape, subjects were asked to respond in writing to openended questions designed to generate data about probable emotional and verbal responses to the old man. The first openended question, "What emotions did you feel in viewing the videotape as you imagined the old man speaking directly to you?" elicited written descriptions of feeling responses to an elderly person in distress. When I analyzed the responses, I found that those who had participated in the Life-Cycle sessions had significantly more positive, accepting attitudes toward the old man than did those who had not participated in the game. When these subjects were asked, "What would you say to this person?" 74 to 92% of all subjects reported verbal responses that were categorized by three mental-health professionals as non therapeutic, indicating a need in this group for repeated exercises in verbal responses using Life-Cycle and/or supplementary instruction in therapeutic communication.
Summary and Conclusion
Life-Cycle is an effective teaching game that invites learners to step prematurely into a simulated old age and situations that are all too common in the lives of the sick elderly. By changing the stereotyped images held by health care personnel of the sick aged to more realistic perceptions, the game offers the potential of ameliorating a major disincentive to choosing a career in geriatric nursing. By increasing empathy in health professionals for the difficulties experienced by the elderly, the game can enhance the quality and effectiveness of their interaction and relationship with geriatric patients.
- 1. Galton L: Don't Give Up on an Aging Parent. New York, Crown Publishers, Inc, 1975.
- 2. Elderly increasing, but few nurses head for geriatric field. Chicago Tribune, Nov 16, 1974.
- 3. US Department of Health, Education and Welfare: The Practitioner and the Elderly, vol 3: Working With Older People. Washington, DC, Public Health Service Publication No 1459, Government Printing Office, 1966.
- 4. Siless S, Estes CL: Perceptions of the aged, adults and youth: The attitude of persons working in the field of aging. Gerontologist 13:82, 1973.
- 5. Coe RM: Professional stereotypes hamper treatment of aged. Geriatric Focus 16:1-3, 1966.
- 6. Jobiason SJ, Knudsen F, Stengel JC, et al: Positive attitudes toward aging: The aged teach the young. J Gerontol Nurs 5:18-23, May-June 1979.
- 7. Raser JR: Simulation and Society. Boston, Allyn and Bacon, Inc, 1969.
- 8. Boocook SS, Schild EO: Simulation Games in Learning. California, Sage Publications, 1968.
- 9. Dewey J: Democracy and Education. New York, Macmillan, 1928.
- 10. Researchers probe reactions to similation games: Report on Education Research, Washington, DC, Capital Publications, Inc, Jan 19, 1972.
- 11. Chaisson GM: Life Cycle: Simulating the problems of aging and the aged. Health Educ Mono 5:28-35, 1977.