It is often true in the teaching of nursing that the crux of a particular content area does not lie in the inherent theories and facts, but more in the attitudes and feelings that students hold about that particular content area. The presentation of the raw content may be decidedly simple, whereas working toward fruitful attitudes in caregivers is considerably more complex. Content about abortion, sexuality, psychiatric illness, and mental retardation are among those that are "loaded," that is, afflicted with negative restrictive societal attitudes and values. When these values are held by caregivers, abilities to provide sensitive, respectful careare limited. Although knowledge itself often loosens negative attitudes, there is no guarantee that presentation of fact, figure or theory alone will render the receiver able to use the content fruitfully with clients. Most content is taught using didactic methods because it is economical. This style, however, is unidirectional and usually focuses on fact or theory, leaving affective areas unattended, hence unchanged.
Content related to the elderly is easily laden with restrictive, negative societal values. These values, when held by providers of health care, cast a worrisome influence on the quality of care received by those over 65 years of age, a growing population of consumers. It is not surprising that nurses and other health professionals hold these negative values, for they reflect the norm in North American society. In our society advanced age is not awarded the status or respect it is in some other parts of the world. Indeed, quite the contrary is often true; elders in our society are often ridiculed, pitied or viewed with disrespect. Children are barraged by media that fail to teach the wealth of talent and experience inherent in the elderly. Family teaching and public education do little to foster positive, fruitful attitudes toward this large sector of the population. Nursing and medical schools also are at fault. Attitudes brought by students often are unexamined and unchallenged throughout their professional education. Although increasingly impressive content on gerontology is included in curricula, mere accumulation of content does little to counteract negative and restrictive attitudes toward the elderly.
Negative values surface in a myriad of ways in the health care system. It is difficult to gain financial and political support for programs for the elderly; the needs of the elderly come second to those of smaller but younger population groups. Studies have shown that almost all health professionals prefer to work with children or younger adults, and that few choose to specialize in geriatrics.1 It is common to see preferential treatment offered to younger patients, or to hear of nurses and physicians who will not consider working in areas in which the primary patient population is elderly. It is well known that staffing in extended care units is a critical concern in the health care system.
These studies conclude that many of these attitudes derive from lack of factual current information about the elderly, and lack of arenas in which stereotypic attitudes can be examined and altered. Educators in all professions should consider these facts seriously when planning curricula that include content on the elderly. They should make sure they do not contribute to the problem, but rather do what they can to correct it.
As part of a year long course on family nursing, The University of British Columbia School of Nursing has conducted a series of three-hour seminars focused on understanding and working with elderly families. The objectives of the initial seminar are to increase consciousness about attitudes toward the elderly, and to realize what to expect in one's own eventual aging. The combined use of guided fantasy and discussion in this seminar has been very useful. The experience focuses on aspects of living that are particularly affected by aging.
This guided teaching strategy was used on four small groups (913) of students, whose age range was 20-48 years. All were RNs in the third vear of the B.S.N, program.
Description of the Strategy
The guided fantasy is structured by headings on a paper handed out to all students, and by specific openended questions read by the teacher (Figure 1). Students are asked to respond to the questions by jotting down descriptive words and statements. They are told that, in the discussion to follow, they can decide which aspects of their fantasy they wish to share or keep to themselves. Soft background music is played as the questions are read, and ample time for response is allotted after each question. The entire fantasy lasts approximately 45 minutes. After a break, discussion follows for approximately 45-60 minutes. The discussion focuses on contributions from the fantasies, known facts and current research about the elderly, and the implications for health care of negative or stereotypic attitudes toward the elderly.
Only selected highlights of the content focused of the post-fantasy discussion are presented in this article. Readers are referred to gerontology texts for more in-depth content.
As do the young and middleaged, the elderly live in a wide variety of different relationships and enjoy significant relationships with many types and ages of people. The people available for these relationships change as years advance and parents, siblings, friends and even children die or change locations. The ability to initiate and maintain relationships also is threatened by physiologic changes or health conditions that restrict movement, socializing, and other interpersonal activities.
Most elderly have been married at least once, and marriage continues to be the preferred relationship option. By age 50, however, the percentage of older persons who are part of a couple drops, due to the death of a spouse. This is particularly true of women. By the time they are 75, although almost three quarters of the men still have living wives, only one quarter of the women have living husbands. Remarriage after the death of a spouse becomes an option available primarily to older men, since the ratio of men to women in the later years becomes increasingly skewed. Only 5% ot women widowed after 55 ever remarry.2
Marriage certainly is not the only source of significant relationships for the elderly. Despite the myth that old people are lonely, many elderly relinquish their roles more warding relationships with friends, siblings, children and grandchildren. Only a very small percentage have no living spouse, siblings or children.2 Studies of relationships between the elderly and their adult children and grandchildren show a wealth of caring and responsiveness.3 "Contrary to popular notions, young adult grandchildren espouse a series of very favorable attitudes toward grandparents."4
Friends continue to play a critical role for those over 65. Although the elderly relinguish their roles more easily outside their families than inside their families, 91% of people over 65 who have friends (and this amounts to 94% of the elderly) see those friends almost every day.2
Students were limited in their ability to see potential satisfying relationships. There was a reluctance among married students to see themselves as ever divorced or widowed, and the tendency among all students was to picture themselves as (still) married, or living comfortably with their children. Some saw themselves living alone but with ready adequate social exchanges with neighbors, friends and family. No one thought they would be part of the 5% with no living relatives. Only rarely did a student mention grandchildren as a source of satisfaction. Only one student mentioned a health professional as a possible significant other in later years. The importance of friends was secondary to that of spouses and children.
FIGURE 1. Fantasy Questionnaire and Group Leader's Comments
Discussion about possible and probable relationship configurations evoked strong familial attitudes about how the elderly "should" live and who "should" be important to them; i.e. the elderly should live with their children; widowed women should try to remarry; older men are incapable of living satisfying lives without wives. Talking about the clinical implications of holding fast to these values illuminates a variety of potential conflicts and problems in working with the elderly.
Health Status and Health Behaviors
Although 89% of the elderly are healthy enough to engage in their normal activities,1 the health status and health behaviors of those over 65 remain a major concern. Almost all body parts and functions experience change as persons age. Muscle strength and lung capacity decrease, all five senses decline, the nervous system and balance become less astute, gastrointestinal processes and cardiovascular function become less efficient. Chronic health concerns are not only common, but few persons over 65 are entirely free of some type of chronic condition.2 Arteriosclerosis, digestive disturbances, hypertension, cancer, arthritis and glaucoma are among those diseases and conditions that increase in incidence with age. Because health is antecedent to activity it is among the most crucial factors contributing to life satisfaction.2 It is no surprise that health is a source of endless worry for the elderly and that it is among the top three conversation topics in this age group.
The practice of effective health behaviors that maintain and enhance physical and emotional health becomes a critical need among the elderly. Eating, drinking, sleeping, exercise and stress reduction behaviors often have suffered from years of inattention or casualness, contributing to poor health status.
It is not surprising that taking of medication often is excessive and performed with a great deal of error. Outdated prescription drugs, lack of knowledge about dangerous drug combinations, difficulty reading labels or understanding directions, and different prescriptions for the same ailment having been prescribed by different doctors, all add up to potential trouble.5 Behavior often is exaggerated or causes diffi culties because of poorly managed medication regimes.
Students invariably found the topic of health threatening. Despite exposure to a wide variety of health problems via previous clinical experience in geriatric nursing, their fantasies were devoid of serious health problems. No student saw herself as suffering from anything more serious than a bit of arthritis or hypertension, some dyspnea upon exertion, or perhaps cardiovascular problems. None saw herself as eventually obese, malnourished, alcoholic, or drug-dependent. None had lost limbs or organs.
Students were invited to do a brief assessment of current health behaviors, such as eating, sleeping and exercise habits, use of chemicals and stress management, and to hypothesize their future habits and physical status by extrapolating 50 years hence. Given this exercise, all students ended up with at least one projected major health problem, and very tenuous future health habits. Discussion about the relationship between ongoing health behaviors and health in old age reinforced the validity of health promotion at all ages and of working with persons who were well but did not practice healthy behaviors.
It is common knowledge that the majority of older persons cannot claim anything close to an affluent style; indeed, a great many have difficulty supporting themselves at all. Financial security for the elderly is a critical social as well as a personal concern. Pension plans and old age benefits rarely are geared to the rapidly accelerating cost of living; widowed, financiallydependent spouses often are left without adequate future income; mandatory retirement often terminates income long before the worker is ready to leave the job. Families can expect income to decline markedly in later years, which can mean compromising the style and standard of living to which members are accustomed. Priorities in spending shift increasingly toward housing and food, and expenditures for holidays, social occasions, recreation, and clothing decrease. The psychologic effects of decreased income, retirement and worrying about finances is considerable, often resulting in a loss of self respect as well as a loss of personal power within the family. In general, the adequacy of financial resources is a great and growing problem among this large portion of the population.
Surprisingly, no student saw herself as poor in old age. Most felt their "savings" and "investments" would provide them with comfortable futures, even though few of the young or middleaged students had given any thought to financial planning or investing. Only a small number knew their parents' financial situations, though many expected to help in some way or were already doing so. Most young students saw themselves as eventual homeowners and able to maintain these homes well into their later years. Regardless of statistics and content portraying a fairly frightening financial situation for most elderly, most students were quite sure this would not include them. Discussion brought forth fear as well as creative suggestions about living arrangements, use of money, and ways of maintaining financial independence for the elderly. There was a great deal of interest in talking with parents and siblings about money, as well in as investigating fringe benefits and retirement plans that were part of employment.
Where and in what conditions older persons live is a topic involving much myth and stereotype. Due to their orientation and exposure, health professionals in particular are likely to believe most elderly live in institutions. In fact the elderly live in a wide range of situations, and only about 5% of those over 65 live in institutions.1 Many maintain their own physical independence and home, with or without a spouse. Many live with siblings, their children or with other relatives in houses, apartments, on farms or on boats. Some occupy units in group living accommodations for the well elderly. In short, just about any conceivable living situation is a possible or existing reality for the elderly. This is not to say that the elderly's preferred living situation can be achieved easily. Shrinking finances, the health status of one's self or loved ones, the limited availability of public or familial assistance, and attitudes of family members, all affect the possible living situation. It is common to hear of adult children who placed a widowed mother in a nursing home because she "shouldn't live alone." That she is competent and responsible is a secondary concern.
Students were divided in their thinking on this issue. Although they thought "most elderly" probably lived in some institution or group arrangement, they fantasized themselves as maintaining their own private homes or living amicably with children. The group immediately was concerned with finances, health status and significant relationships, discussing the practicality of actually managing this feat, thus establishing clearly the interrelations among the various content areas.
How the elderly spend their time, to what use they put it, is an area of increasing attention. Given mandatory retirement and an increasing lifespan, there is a growing number of senior citizens facing as much as 20 to 30 years of post-retiremen living. Although women who have been homemakers experience less struggle than do their previously employed male or female counterparts, structure and use of time is an issue faced by most elderly. Some elderly manage to continue working beyond age 65, especially if employed in an area in which mandatory retirement is not pertinent. Self-employed elders in farming, business, the arts, writing, etc. often work for years after their peers have stopped.
Alterations in home activities are common after retirement. Establishment of a comfortable familial equilibrium suffers from disagreements about division of household labor, boredom, loss of self esteem, and changing patterns of interaction.6
Some elderly people develop second careers after they have been retired. Volunteer work, grandparenting, hobbies, church activity and recreation also offer many elders a wide variety of fulfilling activities. Again, the impact of logistics and health status greatly affects possible daily activities. Activities for the physically well mobile elderly in their own homes differ markedly from activities for the disabled or ill elderly in an extended care unit or nursing home.
The students' fantasies ranged from spending much time traveling, to still working at age 85, to continuing to carry out "regular activities," whatever they might be. A conflict in values about achievement and accomplishment vs. inactivity, unstructured leisure time, and mental activities surfaced quickly in most groups, evoking discussions on the impact of one's personal philosophy on the choice of daily activities. Earlier content on health and other areas became part of the discussion, again establishing the interrelationships among content areas.
Sexuality among the elderly has been studied inadequately; it is still permeated with myth and misconception. Despite the common opinion that the elderly are likely to be asexual, or "dirty old men," satisfying sexual activity can continue throughout life. This is possible even with changes in sexual function caused by aging. There is no definite cutoff point for sex. Maintaining sexual activity throughout life probably is the most valid recommendation for remaining sexually active when old. Sexual feelings and capacity are affected greatly by one's personal value system, previous experience, current health status, and the availability of partners. There is variety in sexual expression among the elderly, with cuddling and caressing often taking precedence over intercourse.7'8 As with younger people, sexual preferences of the elderly ovary.9
Although the students who predicted they would be married when old saw themselves as sexually active with their spouses, most students projected that they would not be particularly sexual, that it had probably been years since their last sexual contact. Only one student fantasized that she would have a lover. Inevitably this topic brought forth discussion about sexuality in one's own parents or grandparents and during discussion colorful examples of sexuality among their own families' elders surfaced. Discussion in all four groups included exploration of solutions to the paucity of male partners during old age, with some talk of sharing husbands and lo vers, or experimenting with lesbianism. Students were very supportive of sexual expression among oldsters and favored promoting changes within institutions to help maintain previously enjoyed intimacies.
Feelings About Self and Others
Perhaps the most damaging of all myths about the elderly is the perception that as a group most are miserable, negative, lonely, bored, or grumpy people who are depressed about their station in life. Media exposure unfortunately has contributed to this, although lately more positive images of the elderly are being presented. Most people tend to know older persons who are pleased with themselves and the lives they have led. Studies show that the majority of the elderly are not miserable, are seldom irritated or angry, and are not socially isolated or lonely.1 Although the greatest impact in old age is said to be changes in self-regard, advancing years do not necessarily lead to depressive attitudes and negativism. The attitude of society toward the elderly probably is more dangerous and destructive than the attitude of the elderly toward themselves or their lives.
Students reflected a certain sadness in response to this part of the fantasy. Several expected to be depressed, especially if they saw themselves as incapacitated or approaching death. Students again were asked to extrapolate their current feelings about themselves and life and to consider future experiences that might positively or negatively affect their current attitudes.
Age And Cause of Death
Many students were unwilling to respond to this part of the fantasy, claiming that they felt superstitious about it. Those who were able to respond claimed death would come during sleep, or very suddenly as in a massive myocardial infarction or an automobile accident. No one projected prolonged suffering or an unpleasant death. A wide range of ages was claimed, with some hoping to die in their 60s or 70s "before they became incapacitated, lonely or senile."
This fantasy experience has shown itself to be a valuable tool in raising awareness about personal feelings and attitudes toward aging and the elderly. Student evaluations rated the experience as extremely meaningful and useful in their clinical work with elderly families. Ongoing attention to student attitudes and values during subsequent clinical supervision made it possible to reinforce the attitude changes begun, and to continue to explore the clinical implications of one's personal attitudes.
Potential uses for this teaching strategy are many. Although in this study it was used with undergraduate nursing students, it could be tailored easily for hospital staff, community health staff, aides, or volunteers working with theelderly.
- 1. Palmore E. Facts On Aging. The Gerontologist 1977; 17(4):315-20.
- 2. Troll L et al. Families In Later Life. Belmont, California, Wadsworth Publ, 1979.
- 3. Johnson E, Bursk B. Relationships between the elderly and their adult children. The Gerontologist 1977; 17(1): 90-6.
- 4. Robertson JF. Significance of grandparents. The Gerontologist 1976; 16(2): 137-40.
- 5. Lundin D. Must taking medication be a dilemma for the independent elderly? J Gerontol Nurs 1978; 4(3):25-7.
- 6. Kopelke C. Retirement as a nursing concern. J Gerontol Nurs 1975; 1(4): 138.
- 7. McCarthy P. Geriatric sexuality: Capacity, interest and opportunity. J Gerontol Nurs 1979; 5(1).
- 8. Friedeman J. Sexuality in olderpersons. Nurs Forum 1979: 18(1 ):92-101.
- 9. Nestle J. Surviving and more: An interview with Mabel Hampton. Sinister Wisdom 1979; 10:19-24
FIGURE 1. Fantasy Questionnaire and Group Leader's Comments