Gerontological nursing research, the systematic inquiry into the health, illness, and care of the aged, though still a relatively recent endeavor, is of interest to all who are concerned with the alleviation of the problems of old age.
Review of Past Gerontological Nursing Research
Basson,1 reviewing selected gerontological literature from 1955 to 1965, found that of 438 articles, 372 were not directly related to research; of the remaining, only 12% could be classified as research articles.
Gunter and Miller,2 analyzing studies in Nursing Research from 1952 to 1976, found 17 on the aged, of which five were clinical, four on attitudes of nursing staff and students, and eight on surveys of characteristics and problems of the aged. For the same period, Gunter and Miller also reviewed the psychosocial literature and found 29 studies, of which nine were studies on the psychosocial characteristics, four on investigations of attitudes of nursing personnel, and sixteen on nursing interventions for the elderly. The authors concluded that, although the number of studies is too small to claim there exists a science of gerontological nursing, it does provide evidence of a developing nursing gerontology.
Brimmer,3 reviewing the International Nursing Index for 1966, 1 97 1 , and 1976, found 38-42% of the articles focused on institutional care, but that there was little emphasis on alternative community care modalities to meet the needs of the aged. Of the 1,091 articles Brimmer reviewed, most were not research oriented. Though there has been a steady increase of gerontological nursing literature, research articles constitute only a small portion of the publications on aging.
I surveyed the five nursing journals most likely to report research on aging. Western Journal of Nursing Research, Research in Nursing and Health, Journal of Gerontological Nursing, and Geriatric Nursing were reviewed fr beginning dates of public at through July 1980, and Nurs Research from January 1977 July 1980. Though not an exhaustive review - nursing research on aging also is published in other professional journals, books, monographs, and reports - it gives an overview of the current status of published gerontological nursing research.
Forty-four research articles were found: 12 of clinical focus, seven on attitudes of health professionals toward the aged, nine dealing with the psychosocial problems of the aged, seven on the problems of the institutionalized elderly, three on health needs of the elderly in the community, two on human sexuality and aging, two on minority aging (specifically blacks), and two review articles on gerontological nursing research. There has been a gradual increase in research in gerontological nursing, but it is limited in scope and depth; it appears that there are no largescale, well-defined research programs that systematically investigate the promotion, maintenance, and restoration of health for the elderly.
Issues in Gerontological Nursing Research
There is indeed need for research, and there are many issues that could be discussed. This article focuses on two major issues in gerontological nursing research: (1) to stimulate research in gerontological nursing, and (2) to make quality health care available to the elderly.
Stimulating Research in Gerontological Nursing
The goal of gerontological nursing research is to provide a sound basis for the practice of gerontological nursing, and ultimately quality health care for the aged. Nursing research studies on aging will not be augmented until there are adequate numbers of nurses prepared to conduct such research. The nursing profession, though theoretically committed to meeting consumer needs, has not responded with educational programs that will prepare nurses to meet the needs of the increasing number of aged - the segment of our society most in need of our care.
Senator Frank E. Moss, in a 1974 survey,4 found that only 27 of 1,054 schools of nursing offered geriatrics as a specialty. In 274 schools geriatrics was integrated as a part of the general course on human development, and only 135 schools provided programs in which students could work in nursing homes. These figures belie the fact that in the U.S.A. there are more nursing home beds (1.2 million) than general medical/surgical beds (1 million).5
The Division of Gerontological Nursing Practice (American Nurses' Association) attempted to gather data in a similar survey and found such a wide variation in how geriatric nursing is being taught that it was impossible to obtain publishable data. (Sister Erika Bunké', personal communication). Most commonly, gerontological content is integrated in bits and pieces into other courses. From personal experience with teaching human development courses to undergraduate nursing students, the amount of gerontology one can include in such a course is small, and it will not give students a foundation for further course work. Yet graduate education purports to and should build on undergraduate preparation.
Brower,6 in a study of graduate programs in gerontological nursing, found only eight schools with valid programs. Her study verifies that graduate programs are at an embryonic stage and that there are many shortcomings in the existing programs. For example, one school of nursing that grants a master's degree in gerontological nursing offered no course on the theories of aging; one two-year program had no identifiable courses in gerontological nursing or gerontology, and another program had only one identifiable course related to aging. Since Brower's report in 1977, the number of programs has increased considerably. According to Sister Erika Bunke, Program Coordinator, Gerontological Division of Nursing Practice, currently there are 24 graduate programs, which is indeed encouraging. However, we have no data on the content and quality of these programs. Though the number of graduate programs is increasing, to the best of my knowledge there are only two or three doctoral programs in gerontological nursing.
These facts illustrate the magnitude of the problem and explain in part why gerontological nursing research is proceeding at such a slow pace: the majority of schools include little if any theoretical and clinical content at the undergraduate level; most students graduate without basic knowledge in the nursing care of the aged; and, at the nursing graduate level, program quality may vary, especially in research, theoretical, and clinical content. As a result, there is an inadequate pool of candidates with strong gerontology backgrounds prepared to enter the field at the doctoral level, and those who do may enter with insufficient preparation. Many graduate students, therefore, must learn basic content when ideally they should be contemplating issues, pondering theories, and developing innovative research proposals. The lack of preparation burdens the student as well as the faculty members, who must try to compensate for the deficiencies in knowledge in a limited amount of time.
Recommendations for Change
If we are to see an increase in gerontological nursing research, we must recruit more nurses into the field and prepare them for research at the doctoral level. We can achieve this goal by recruiting students early in their careers, involving them in research programs and, through our enthusiasm, motivating them to pursue careers in gerontology. Undergraduates should receive both clinical and theoretical instruction in gerontology. Students who have more opportunities to care for the elderly during their early educational years should be more interested in working with the aged after graduation, and be more inclined to seek graduate programs in gerontology.7'8 Brower notes that informed, enthusiastic teachers are essential if we are to motivate students to care for the aged. If content is presented knowledgably and enthusiastically, students respond with interest and excitement. Recently, after giving several lectures on a crosscultural comparative study of the care of the institutionalized aged in Scotland and the United States, in an undergraduate course in human development, the students became so concerned about the lack of quality care for the aged in the United States that they approached faculty members and asked that arrangements be made to have an elective course in gerontological nursing in their senior year. These students realized that a large percentage of their future patients would be the elderly and that their program was not preparing them to meet the needs of the aged. Students are ready and eager for gerontology; their undergraduate programs must include courses that will give them solid foundations for graduate education.
Graduate education in gerontology at the master's and doctoral levels is in the early stages of development, and faculty resources for teaching and research are limited. The number of nurses being prepared is far below that needed if we are to research the growing health needs of older Americans. Though there is a need for increasing the number of programs, because we lack well-prepared faculty we should at this time strive toward developing a limited number of quality programs.
There are two ways to achieve this end. First, nursing faculty must identify the theoretical and clinical content for graduate study and launch programs only when there are adequate resources to support a quality program. Second, though there is not a well-defined scientific body of knowledge in gerontological nursing, developments in gerontology have flourished since World War II and nursing educators, by incorporating the research findings of the biomedical and the social and behavioral sciences, will find more than an adequate body of knowledge on which to build programs and to develop research specific to the nursing care of the aged. Gerontology, an integrated discipline, and gerontological nursing, have a common goal: the alleviation of the problems of the aged. We need to increase communication and collaboration, in teaching and research, between nurse scientists and gerontologists. Each discipline will gain from the other. Nurses, for example, have access to clinical settings and data that may be inaccessible to social scientists. Biologic and social scientists are making valuable contributions to gerontology that are relevant and applicable to the development of gerontological nursing as a scientific discipline; collaborating with them would ease the dearth of gerontological nurse researchers.
The graduate program in longterm gerontological nursing at the University of California, San Francisco, is an example of an excellent program that prepares nurses for leadership in a variety of settings that serve the elderly and other long-term clients. The faculty in this unique program encourage students to take courses in such related fields as Human Development, Medical Anthropology, Medical Sociology, Health Policy, and Psychology. The multidisciplinary approach provides them with an exceptional background to deal with the multiple problems of the aged.9
Making Quality Health Care More Available to the Elderly
Making quality health care available to the elderly depends in part on the resolution of the issues discussed previously. With increased research activity and subsequent application of research findings, the quality of health care for the elderly will improve. To achieve this goal, however, there is an urgent need for increased research in community and institutional care of the aged.
Community Care. Though for decades nurses have provided the basis of community health care, there has been little nursingresearch on community care of the aged. Archbold10 examined the effect on adult children of caring for disabled parents in their homes; Sullivan and Armignacco" reported on the effectiveness of a comprehensive health program for the well elderly; and Franck12 described the needs of the aged in one county in Iowa and suggested that the development of a coordinated, comprehensive, multidisciplinary approach to home services would enable the elderly to remain in their homes longer and improve the quality of their lives. Similar studies would be valuable in planning future community care programs. An important area for research is the identification of health needs of the elderly in the community and the development of preventive and continuing care programs to meet these needs. Nurses, with their broad preparation in the biologic, psychologic, and social sciences, are uniquely qualified to develop and implement such programs. It is well known that in the U.S.A. home health services for the elderly are limited and poorly developed, that there is not a comprehensive range of services, and that the current available services do not meet the most pressing needs of the aged. There are, however, some countries that have been progressive in their approach to community care of the elderly. The Scandinavian countries and the United Kingdom have well-developed community care programs that provide a broad range of comprehensive services. Cross-cultural comparative studies would provide valuable insight for developing similar programs in the U.S.A.
Community Mental Health Care.
There is a need for research that will investigate the mental health care needs of the aged and the availability and utilization of community mental health services. It is difficult to assess the extent of mental illness among the elderly. Community surveys suggest that 5%-22% of the aged have moderate to severe psychiatric problems,13 yet account for only 2% of patients seen in psychiatric clinics, and an even smaller percentage of patients seen by private psychiatrists.14 Butler15 notes that physicians, nurses, social workers, and other professionals pay little attention to the mental health needs of the aged, and that community health centers have failed to provide the necessary services.
Deinstitutionalization - the discharge of residents from state mental institutions to local communities - provides perhaps the most dramatic illustration of ineffective planning and subsequent failure of community mental health care. A review of this event will demonstrate effectively how, in the absence of research and planning, well-intentioned programs tend to fail.
In the early 1960s, mental health services in the U.S.A. underwent a massive reform. The introduction of antipsychotic drugs in the early 1950s was one factor that led some authorities to believe that thousands of patients who previously were confined to institutions could be cared for as outpatients in the community. In 1955, Congress established the Joint Commission on Mental Illness and Health to evaluate services for the mentally ill and to formulate a national mental health program. The commission published a report in I960 that provided the foundation for President Kennedy to address Congress, urging a "bold new approach" to the treatment and management of mental illness, and led to the passage of the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. The legislation called for the establishment of community-based centers and promised federal funding for such facilities.16 The new concept of community mental health promised treatment and rehabilitation of the severely ill mental patient within the community, and promotion of mental health in general. The goal was to develop extensive community-based centers that would offer comprehensive, coordinated treatment and rehabilitation services.
For many reasons these goals were not realized - mainly unsound fiscal planning, undefined strategies, and the deinstitutionalization of patients before community programs were developed. A major impetus to discharge the mentally ill from institutions was the enactment of the Supplemental Security Income (SSI) program that took effect in January 1974. The program offered full support payments for elderly persons who were living neither with relatives nor in institutions. Normally, states pay all costs for the care of those in public mental institutions. If the state releases patients from mental hospitals, however, and reports them as indigent elderly, the federal government will pay the total cost of care. 17 This policy provided states with the financial incentive to accelerate deinstitutionalization and some legislatures, eager to decrease the financial burden of state mental hospital costs, reduced their populations quickly and dramatically. In California, for example, the state hospital system was reduced from 35,743 patients in 1963 to 6,689 in 1974; on the national level in that same period, the total population in state and county mental hospitals decreased by 57%. I8 Fifty-six percent of those discharged were elderly residents. The SSI program, probably more than any other factor, was responsible for the discharge of elderly people from hospitals into the community without adequate facilities and programs.
It is difficult to document what happened to most of these elderly people; no records were kept of where they went, and we do not know how many died before, during, or shortly after transfer. It has been estimated that about 50% of those discharged entered nursing homes; the nursing home industry experienced its greatest growth when the mental hospitals were vacated. In fact, when it was announced by the mental health department that a group of patients was to be discharged, proprietary nursing home owners, eager to fill their beds, arrived in vans at the state mental hospitals and offered bribes of $100 for each person released to them.17
Although the nursing home provided little or no therapy for the mentally ill elderly, living conditions were probably even worse for those discharged into the community. There are no data available on the number of elderly living in some form of sheltered community housing. Many drifted into substandard inner-city housing; rather than being integrated into the community, they were segregated into ghettos in some of our major cities.
Chicago, for example, estimated that it had a psychiatric ghetto of 12,000 to 15,000 former mental hospital patients who were living primarily in unlicensed facilities.17
In California, the board-and-care home was the community facility used most; the homes operated for profit by unlicensed, untrained staff provided virtually no treatment and rehabilitation and made little attempt to integrate the mentally ill into the community. It has been estimated that only 10% of the patients released to thç community from 1968 to 1973 had any contact whatsoever with community health clinics.18
The tragic and incredible outcome of this program for the mentally ill elderly illustrates the great need for research before, during, and after implementation of such plans, and the need for nurses, physicians, and other health workers to participate in that research. Further, it demonstrates the importance for collaboration between policymakers and health care professionals (practitioners and academicians) in the development, implementation, and evaluation of new and emerging health policy. A program developed recently at the School of Nursing at the University of California, San Francisco addresses these issues. In July 1980, the university received government funding to establish the Aging Health Policy Study Center to investigate the effects of existing social and economic policies on the care of the aged as a guide to future policy development.
Care of the Institutionalized Aged. In 1974, the Western Interstate Commission for Higher Education, the Western Council on Higher Education for Nursing,, and the Regional Program for Nursing Research Development surveyed 238 nurse faculty members to determine research priorities in nursing. The survey pointed to three areas: priorities important to the nursing profession, priorities for which nursing should have responsibility, and priorities that would have the most influence on patient welfare. An item in the third category (priorities that would have the most influence on patient welfare) was: "Find means of enhancing the quality of life for the aged in institutions."19 The results of the survey indicate clearly that nurse educators consider care of the institutionalized aged to be of first importance; it has been a problem for several decades. When I report my research findings on the care of the institutionalized aged, it is not uncommon for someone to remark: "Well, at least only 5% of the aged are in nursing homes." (Or, because the institutionalized aged comprise so small a percentage of the total aged population, it is more important and profitable to direct our attention to the 95% who live in the community.)
Researchers are challenging the 5% figure, and some studies suggest that about 20% of elderly persons will spend some time in nursing homes during their lifetimes.20Further research is needed to confirm this figure but, whatever the percentage, the fact remains that the care of the institutionalized aged is a major problem in our society that needs and deserves the attention of the nursing profession.
Recently, friends asked me to locate a nursing home for their elderly aunt. We visited one that is considered one of the finest in the area. After a brief visit, this elderly woman became very agitated and vowed that if she were placed in that home she would commit suicide the first night. She is not an isolated case. Many elderly fear admission to nursing homes, and their fear dramatically illustates the need to provide better facilities for the aged.
Past research on the care of the institutionalized aged has focused primarily on their psychosocial needs. Investigators have examined specific environmental factors to determine variables that increase or decrease morale or promote satisfaction or dissatisfaction among nursing home residents.23-25 The use of reality orientation and group therapy with the confused elderly has been the focus of other researchers.26-28 A few clinical studies have addressed such problems as drug interactions and constipation.29'30 There is a need, however, for additional clinical studies on such disorders as incontinence, confusion, immobility, and the use of sedative-hypnotic drugs.
Research in the care of the institutionalized aged conducted by nurses has been somewhat limited. However, a substantial body of literature by other scientists indicates that nursing home staff members spend most of their time attending to the physical and medical needs of the elderly, and that psychosocial, personal, and affective needs are given little attention. These findings are paradoxical, especially as the bulk of research conducted by nurses has been on the psychosocial care that is considered an integral part of most nursing curricula. Traditionally, nurses have been oriented to the caring as well as the curing components of their patients' therapeutic regimes."
Attention to personal needs often is most important to the elderly; in some countries an effort is made to meet these needs. In Great Britain and Denmark, for example, the elderly are provided with meaningful work and recreational activities to keep them as active and independent as possible. This quotation is from a brochure given to the elderly when they enter a particular Danish institution:
With this small pamphlet, you are welcomed as an inhabitant of Bispebjerghjemmet. This will from now on be your home, and the board, the superintendent and his wife, and the staff hope that you will quickly feel at home here. The ward where you shall stay has 24 rooms, each with its own toilet and bathroom, as well as a common sitting room with color television. Further, there is a tea-kitchen were everybody has his own cupboard and where you or your relatives can make coffee or lea. The home subscribes to different papers which are in the sitting room; they must not be removed. There is a guestroom available to relatives coming from far away so that they may have the opportunity of staying overnight with you. In addition to all of the mutual gardens around the home, there are small garden plots where inhabitants who would like can nurse flowers. If you are dependent on a wheelchair, you can get a garden at the level of the chair. The staff will help you buy plants, etc. There is a library in the basement; if you are fairly mobile, you can go down by yourself and borrow books. If not, the bookcart will come around in the wards once a week.
These small considerations make a facility a home rather than an institution; the homelike environment gives the elderly some independence and choice in their lives, and the provision of current reading materials keeps them in touch with reality. I have often thought that if there were calendars, clocks, and newspapers in our nursing homes, and if the elderly were taken outdoors and into the community periodically, We would have less need for reality-orientation programs.
Nurses in American nursing homes are not oblivious to the psychosocial and personal needs of the elderly, yet often these needs are neglected. It is important to learn why such care is not given. We know little about the dynamics of nursing home care and the complex interrelationships of the financial, political, social, and administrative factors that help or hinder nurses in providing good care for the aged. Cross-cultural comparative studies may help us to find answers to these questions.
In a recent comparative study of long-term care in Scotland and the U.S.A., I found a marked contrast in the quality of care in the two institutions investigated. In analyzing the data, two institutional barriers to quality care in the U.S.A. were: (1) lack of leadership and responsibility by professionals (doctors and nurses) for the care of the aged, and (2) accountability for care, which lies not with health professionals, but with the proprietor of the institution (who hopes to make a profit) and with the State Department of Health.31
If the philosophy of gerontological nursing is to provide quality care for the elderly, we must find ways to restructure the system and remove the barriers so that humane care for the elderly will become a reality. We need longitudinal studies that may indicate how nursing care can improve the quality of life for the elderly in nursing homes.
There are encouraging developments to suggest that there is support for nurses to bring about change. Senator Daniel Inouye has introduced a bill that will provide third-party reimbursement for geriatric nurse practitioners; the bill states that all facilities must hire practitioners. If the bill is passed, however, it will take some time to implement it. Presently there are not enough nurse practitioners to fill such positions.
To make quality health care more readily available to the elderly, we must have nurses who are qualified to provide that care. I strongly recommend, therefore, that (1) gerontological nursing is made a part of the curriculum in all schools of nursing; (2) schools of nursing prepare geriatric nurse practitioners for leadership roles in long-term care institutions; and (3) the professional organization begins action that will make the salaries of nurses in nursing homes equal to the salaries of nurses in acute care hospitals.32 In Scotland all nursing staff members in geriatric institutions receive salaries equal to those of other nurses, and a small annual bonus in addition. We cannot expect overworked, underpaid, and poorly prepared nursing staff to give quality care. We cannot attract highly qualified nurses to positions that pay substandard salaries.
We may face considerable resistance before achieving these proposed goals. A society that values the young more than the old, and a health care system that traditionally has focused on care of the acutely rather than the chronically ill, may be unwilling to change the focus of care and to pay the cost of quality care for the aged. We now have an aging society; with further advances in the prevention and treatment of cardiovascular diseases, the size of the elderly population will increase greatly. It has been estimated, for example, that if people would stop smoking and eat less of certain foods, and if air pollution in the major cities were reduced, the mortality rate from cardiovascular disease will be cut in half; this would increase life expectancy by three to five years.33 Although we have substantially increased the human lifespan during the 20th century by the prevention and cure of acute infectious diseases, we have made less progress in the prevention and treatment of chronic illness - the problems of old age - and in the delivery of health care to the chronically ill aged. Providing health care for the elderly must be foremost among our future research efforts if we are to help the aged remain as well and as independent as possible. Nurses can play major roles in developing health care structures that will serve the elderly adequately and alleviate many problems of old age, thereby enabling people to live not just longer, but better, lives.
Undoubtedly, there is enough talent in the nursing profession to address and resolve these issues. It is a heavy responsibility and a great opportunity for nurses to make a valuable contribution to our elders and to our society.
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