A void exists in nursing education: the needs of the well and ill elderly are not being met. Consider these facts:
23 million people, more than 10% of our population, were over 65 in 1970.1
The 1980 census is expected to show this percentage increasing to 15%.2
About 1 million, or 4%, of these people receive nursing care in long-term care facilities. Another 80% suffer chronic health problems requiring attention from health professionals in the community.
The elderly use 22% of all prescription and non-prescription drugs sold in this country.
Despite the evident need, nurses spend little time learning to care for this group of people. A 1968 study showed a serious lack of gerontologie content in undergraduate nursing programs.5 In 1980 the same situation existed, despite funding incentives6 and increases in graduate level preparation of gerontologie practitioners.7
In an attempt to assess the situation in Delaware, the Delaware State Division of Aging surveyed RNs and LPNs who worked with the elderly. Based on the survey response, the Division allocated funds for a course in gerontologie nursing aimed at RNs and LPNs working with geriatric patients in long-term care facilities in Delaware. My task was to develop this course and teach it in the spring of 1979.
A proposal was submitted to the Division of Aging for a one-year grant to develop, implement and evaluate a course to be taught in eight sites statewide. The final grant of $10,000 for five months was sufficient to fund only implementation of the course at one central site.
The budget items for the course included:
I. Salaries and benefits:
A. Full time (5 months) for an MSN-prepared nurse to coordinate and teach the course and administer the grant
ANALYSIS OF PARTICIPANTS
FIGURE 1 :
B. Part-time secretary (100-150 hours) $500
II. Supplies and Materials (including purchase of filmstrips) $600
II. Travel $400
IV. Postage, publicity, phone, mise $1700
Travel costs included travel to one out-of-state workshop as well as weekly to the teaching site. Secretarial costs were expected to decrease after the initial preparation of materials.
The cost to participants was limited to the textbooks. The grant provided funding for all other expenses.
The course was aimed at nurses in active practice; therefore, it was essential to plan around existing work schedules. Tuesday and Wednesday afternoons from 2-4 p.m. were chosen for class time. The same content was taught on both days, enabling participants to attend on either day. Because most agencies actually "donated" an hour per week per nurse for those who worked the 7-3 or 3-11 shifts, many participants were able to take the course by adding only one hour per week to their schedules.
The course provided 30 contact hours and lasted 15 weeks.
A centrally located long-term care facility was chosen. All participants were within a 45-minute drive of the facility.
Students could obtain two undergraduate semester college credits for completing the course or they could choose to audit. The audit alternative was offered to provide a less threatening option for those who had been out of school for many years.
The course was approved for credit by the Academic committee of Wesley College, Dover, Delaware, an accredited junior college. The course met college standards for length, measurable objectives, and prepared faculty.
Additionally, all participants received continuing education credits approved by the state nurses' associatioion.
Sixty-six nurses completed the course: 48 RNs and 18 LPNs. Thirteen of those who registered withdrew without attending class. Those contacted cited schedule conflicts at work as the reason for withdrawal. One nurse withdrew because of conflicts with other course work. About 80% of the participants were employed at the facility used as the teaching site.
The analysis of participants is shown in Table 1.
Course development included a literature review and consultations with educators and practitioners of gerontologie nursing. THe course objectives were broad purposely as participants had had limited contact with formal courses on aging. This allowed the staff to cover a variety of topics and to provide basic knowledge within the sphere of gerontologie nursing. Figure 1 lists these objectives and shows when they were met on a weekly basis. Emphasis was on five content areas: assessment, normal aging, common pathophysiology seen in the aged, nursing intervention, and teaching.
Assessment. Basic information was provided about nursing assessment of the adult, with emphasis on those body systems affected most in the geriatric patient.
Normal Aging. This content provided a baseline for assessment. It also allowed participants to differentiate normal aging changes from pathology in the elderly.
Pathophysiology. Only the most common physical and mental problems affecting the elderly were discussed in this beginning level course. These problems are listed in Table 2.
Nursing Intervention. The participants needed concrete suggestions about how they could impact personally on the mental and physical health of their patients. The course included very specific nursing measures that participants could use to promote normal aging and/or to prevent or alleviate the problem under discussion.
Teaching. Participants were encouraged to share information with other staff members and to use it to develop patient teaching plans. A class on teaching-learning concepts provided a core of knowledge. Other classes presented specific teaching tools and discussed ideas for information exchange.
Table 2 delineates the specific content of the course.
Behavioral objectives developed for each of the topics were distributed to participants. They helped students focus out of class preparation and were useful in guiding class discussions. Table 3 lists specific examples of behavioral objectives for two topic areas.
Most classes followed the lecture/ discussion format to utilize the expertise of the nurses present. Audiovisual materials were used to show various aging changes and intervention techniques. Resource people experienced in working with elderly clients spoke to the participants. One speaker was a nurse experienced in remotivation and reality orientation for patients with chronic brain syndrome. Other speakers included a public health nurse who ran a geriatric clinic, the director of a local senior center, and the director of a homemaker/meals on wheels service. These guests provided information on the effects of various environments on the aging process. Although initially money was budgeted for the speakers, they all refused to accept payment.
EXAMPLES OF BEHAVIORAL OBJECTIVES
Students were expected to participate in their own learning through completion of three independent projects and one class presentation. These helped foster independent learning and allowed participants time for in-depth investigation of special interest areas. A list of suggested projects was distributed. Students could also develop their own projects, with the instructor's approval. Some of the suggested projects included:
1. Observe the grocery basket of an elderly person in the store (or accompany an elderly friend on a grocery trip). Write a statement regarding the nutritional value of the purchases. Would the food purchased provide a balanced diet?
2. Assess the availability of at least two of the following resources for the elderly in a specific geographic location (e.g., city, county, town etc.): (a) transportation, (b) health services, (c) social groups, (d) stores. Write a short report.
3. Discuss with a non-institutionalized person over 65 the drugs taken currently. Write a brief assessment of that person's knowledge about and compliance with the drug regime.
For class presentations, student groups presented segments of the class covering single objectives. They chose their own teaching methods. The presentations helped students to meet the teaching objectives for the course. Methods of presentation used by students included lectures, charts, films and a skit. One group demonstrated nursing assessment skills on a patient invited to class. Presentations were limited to 20 minutes. Most presenters were able to finish within the time limit, although some groups used extra time. (In classes of 50 or more students this method would have limited application.)
Evaluation of Student Learning
Student learning was assessed by evaluating performance in four areas: class participation, class presentation, independent projects, and examinations. Class participation was evaluated subjectively by the instructor. Students were expected to make pertinent contributions to class discussions. Both frequency and quality of the contributions were considered in grading. Grades for class presentations depended on how completely the chosen objective was covered by the group. Generally, all group members received the same grade. An attempt was made to grade the presenters on the content rather than on teaching style. This was difficult, as some teaching styles interfered with the group's ability to understand the point. Independent projects were graded on completeness. Midterm and final examinations provided the final evaluation tools. These examinations consisted of essay and shortanswer questions. Take- home examinations were planned to decrease the pressure on participants, half of whom had had no formal education in 10 or more years.
GRADING OF COURSE
Participants found that the tests allowed them to consolidate their learning in a non-threatening atmosphere.
The course grade was based on a 1000 point total, allocated as shown in Table 4.
Favorable comments by participants, final written evaluations, and surveys completed by agencies with participating staff indicated that the course met the stated objectives. Participants indicated on written evaluations that they could use the course material daily. Most of the class believed that the emphasis on teaching-learning concepts, including class presentations, helped them to develop more productive working relations with aides and attendants.
Students rated the topics on the basis of applicability and interest. Among those topics rated highest were:
1. Normal physical change and aging
2. Organic brain syndrome
3. Depression and suicide
4. Sensory training, reality orientation and remotivation
5. Bowel and bladder continence and fluid balance
6. Communication disorders, and
7. Drugs and the elderly.
All nursing directors who responded to the agency survey stated that the quality of care in their facilities was being affected positively by the course. Staff workshops and new programs were started as a direct result of the course.
Participants requested in-depth followup on all topics, particularly assessment skills. Content on cardiovascular problems also was requested.
Suggestions for Program Developers
A. Try to bring the program directly to the participants
Although the course described did attract nurses from agencies other than the one used as a teaching facility, the number from these other agencies was small. Travel and scheduling problems at work seemed to be the major problems. Having the course at the work site eliminates travel and decreases scheduling difficulties, thereby increasing attendance.
B. Plan the time for the course around existing work schedules
This course was planned to take advantage of a slow period in the work day. This enabled the agency to free more staff to participate. Another option would be to offer two sections of the course during different shifts (e.g., days and evenings) to allow nurses to attend when not working.
C. Try to reach others caring for the elderly, especially nurses in acute care facilities and in the community
As stated, 80% of our over-65 population lives in the community and requires health care for chronic health problems.3 Much of this care is given in short-stay hospitals. In the first eight months of 1979, 27% of admissions to general hospitals nationwide were patients over 65 years of age, although they comprise less than 15% of the population. This same population stayed in the hospital 57% longer than the younger patient.8
Nurses in these settings need to be aware of the effects of short-term illness and hospitalization on their elderly patients. They also need increased knowledge to differentiate normal aging from illness in the aged.
D. Provide the participants with required readings in the form of texts or handouts whenever possible
Nurses in most long-term care facilities have limited access to medical libraries. As adult learners with jobs and families, often they are neither willing nor able to spend hours doing outside reading away from home. For this course, the majority of participants came to class prepared when the assignments were drawn from the text and handouts. This improved class discussion and aided learning. Also, the texts and handouts remain a part of each nurse's gerontology library, and provide resources for staff and patient teaching.
The interest and excitement generated by our course supported our initial premise that more educational opportunities are needed in gerontologie nursing. This need can only increase as our over-65 population grows.
- 1. Tirhy A, Matasanos L. Physiological parameters of aging. J Gerontol Nurs 1979: 5(1):42.
- 2. Falconer M. Altamura M, Behnke H. Aging Patients: A Guide for Their Care. New York. Springer- Verlag. 1976:ix.
- 3. Combs K. Preventive care in the elderly. Am J Nurs 1978; 78(8): 1339.
- 4. Hallister L. Prescribing drugs for the elderly. Geriatrics 1979; 8:71.
- 5. Moses D. l«akc C. Geriatrics in baccalaureate nursing curriculum. Nurs Outlook, 1968; 16:41.
- 6. Gress L. Gerontological nursing and the curriculum. J Gerontol Nurs 1979; 5(6):40.
- 7. Anonymous. Current and future needs in geriatric education. Pubi Health Reports. 1979; 94:76.
- 8. Bachoffr H, Cohen C. Inflation continues to hammer hospitals. Hospitals 1979; 53(21 ):65.
ANALYSIS OF PARTICIPANTS
EXAMPLES OF BEHAVIORAL OBJECTIVES