The meaning students derive from experiences with well-elderly clients has been insufficiently explored. Spradley1 states, "before you impose your theories on the people you study, find out how those people define the world."
This article reports on a study of how a group of nursing students defined their reality of human responses during a home visit. Knowledge of their views can assist in identifying concepts and teaching strategies for preparing practitioners in gerontological nursing.
The purpose of the research was to answer the question: What domains of meaning are used by student nurses in portraying their experiences with elderly clients? Specific questions included: How does the student nurse view elderly clients? How does the student learn to recognize care-eliciting, care-receiving, and care-giving activities for elderly clients? This research is based on an earlier study by King and Cobb.2
The study is grounded in two major concepts: culture of nursing students and care. Spradley1 defines culture as "the acquired knowledge people use to interpret experience and generate social behavior." This concept has a strong link to symbolic interaction theory.3
Some components in a culture of students have been outlined by Oleson and Whittaker.4 Their work was primarily concerned with the "human condition" of the student and used symbolic interaction as a framework to analyze students' encounters with various others, which in turn enabled the students to define, choose, and act. The care construct is derived from the work of Leininger,5,6 Aamodt,7 Watson,8 and others. Aamodt delineates care as taking care of self and others.7 Griffin states that care is a study of who we are and how we relate to others.9
Methodology - Twenty-eight baccalaureate students in their first clinical nursing course in the University of Arizona College of Nursing recorded their thoughts, feelings, and observations during a six-week (one hour/week) home visit experience with well-elderly clients in the 1980 spring semester.
A content analysis protocol along with the technique developed by Spradley was used to discover domains of meaning, and identify cultural themes.' Domains have been abstracted from the students' recordings and represent a first step in discovering their view of the encounter. The domains presented in this article are:
1. Being an Elderly Client;
2. Doing for Students;
3. Obtaining Good Feelings; and
4. Ways to Handle Feelings That are Hard to Deal With.
Being an Elderly Client
Elderly clients are perceived by students as talented, open minded, talkative, and proud of their accomplishments. They are fun to be with. Students enjoy visiting people who are personable, helpful, and mentally alert, and who have a sense of humor. They are less attracted to people who feel alone and depressed.
Many individual characteristics are mentioned in the students' observations, including "overweight," "lackluster eyes," "doesn't look his age," as are various ailments such as hypertension, asthma, tachycardia, Parkinson's, and arthritis. Their clients engage in a variety of activities to stay active, such as exercising, attending classes, reading, doing volunteer work, and helping neighbors. Students view these activities positively. They can visualize hope as they consider their future aging process.
At other times the elderly client is perceived as being alone, depressed, and lonely. One student wrote: "Mr B. appears very lonely. He says that he has no friends to take him anywhere, that nobody wants to see a legless man." Another wrote: "She was depressed; this was particularly sad since this was our last day together. I encouraged her to discuss her feelings, and I told her that it made me sad to see her unhappy. " These examples draw attention to the social isolation that can envelop the elderly as they lose family and friends. Being isolated may create an intense loneliness and depression. The student visit signifies an interruption in this process, if only for a brief period of time.
STAGES IN WHICH STUDENTS LEARN FROM ELDERLY CLIENTS
Doing for Students
Elderly clients engage in helping and sharing activities during the home visit. They give students a nice welcome, serve them food and drink, and they break the ice for those who are anxious in their new role. Students wrote repeatedly about how their clients make them feel at ease: they say nice things ("you are the best-mannered student I've ever had," "you will be a good nurse," "you are so gentle," "you have done a lot for me"); give guidelines for the visit ("do a good job, not sloppy, " "it is all right to do anything for class"); and talk about sexuality ("She brought up the subject of sexuality and gave me every bit of information I needed plus more. It was a relief to me.").
The most prominent thing elderly clients do for students is disclose. They show cherished items, such as family pictures and memorabilia; talk about the old days, recalling past trips, important times, and career highlights; and express concerns, (eg, "he expressed guilt about watching his wife get worse and that he was not able to help or even discuss this with her," "She is very concerned about her husband's ill health. As we were talking she was tugging her fingers, her mouth quivered, and her eyes watered."). They express needs (eg, "She asked me if I would visit her even after the course was over, " and "He asked me if I would drive him places."); and express feelings. For example, happiness is expressed about a visit: "She keeps telling me how happy she is that I am coming," and sadness is noted on termination: "He seemed very sad and expressed repeatedly how much he'll miss me." Another student wrote: "He quoted Brutus from Julius Caesar: 'If ever there is a time to shed tears, shed them now. '"
Hugging, kissing, patting, reaching for, and squeezing hands were ways to "touch for love. " The need for touch in the elderly is essential, but often there are limited opportunities for human contact. Tiie student visit can be a time for renewing one's sense of being.
Obtaining Good Feelings
In the process of building a therapeutic relationship with their clients, students obtain good feelings in various ways. These can be viewed sequentially in three stages, as shown in the Figure. The first stage, working with the elderly, focuses on the activities students initiate with clients: talking, bringing food, showing affection, and giving assistance with caretaking activities.
The second stage, hearing positive things, and learning from them, focuses on students as receivers of information from their clients. The third stage, experiencing success, refers to times or activities that give students the feeling that they are nurses. Each of these stages is illustrated below.
Stage 1 - There are two kinds of conversation in which students engage their clients: business and social. Business conversation involves asking health history questions, whereas social conversation centers on the nonwork talk, such as exchanges about the weather, plants, and politics. Both business and social conversation can generate good feelings. Students' comments evidence these feelings: "It's the last few minutes that I like the most - the social part, where we express an appreciation for each other"; "What is more important to me than obtaining data is that I am beginning to see an outline of the man's character. I feel this will go a long way toward establishing a relationship that will allow insight into the problems of aging."
Students also obtain good feelings by bringing food (eg, cupcakes, cake); showing affection (eg, hugging, touching, sitting close, bringing gifts); and giving assistance (eg, administering eye drops, making a chart for urine testing, giving information on diabetes).
Stage 2 - In listening to their clients, students frequently hear messages that make them feel good. Students like hearing positive things (eg, "she told me I had done a lot for her," "she told me she had a very full and satisfying life and had no regrets," "she was pleased with my comments"), and they like learning from them (eg, "in these few weeks I have learned so much that will help me throughout my life," "I learned from her wisdom.").
Stage 3 - Having a productive day, a successful first visit, and being in control are additional ways students receive good feelings. They particularly enjoy doing things that make them feel "like a nurse," such as having nurse-patient interactions, having a client who confides, making a nursing diagnosis, and doing a physical exam. These last activities underscore the process of role development in the student. To experience success with an elderly client is a first step in the process of becoming a professional.
Ways to Handle Feelings That are Hard to Deal With
Sometimes during the home visit students feel nervous, uncomfortable, pressured, disappointed, frustrated, depressed, afraid, shocked, tired, embarrassed, or sad. These feelings are linked with the full range of emotions associated with the human condition. Three of these will be illustrated through student comments.
Shock - "He took me to the kitchen to show me what he eats: frozen waffles, cookies, milk with ice cream, Ovaltine, pie, a beer now and then, and soda pop. I was in shock." Students also become shocked by seeing deterioration in a client's mental status, having an uncooperative client during the physical exam, and hearing about a client's drinking habits.
Sadness - Hearing that the client has no real friends nearby, seeing a client's unhappiness, discussing the last visit, and saying good-bye were characterized as sad. During the last visit expressions of loss were made, such as "I really will miss him," "it is a sad day," "it will be a real loss," and "I feel a little empty."
Discomfort - Certain situations during the visit make the student uneasy. For example, asking personal and sexual questions, dealing with physical disabilities, separating the social from the therapeutic relationship, having nothing for small talk, and talking about death were some subjects that made students uncomfortable. This feeling may be particularly acute for the beginning student who is working through his or her attitudes toward aging.
Cultural themes were developed by the researchers, based on the work of Opler,10 and represent more general features of the student nurse-client encounter. The themes are:
1. "They help me learn how to care;"
2. "Some things are shocking and make me feel nervous;" and
3. "It is hard to say good-bye."
"They help me learn how to care" illustrates the idea that learning is a vital part of the home visit experience. The student is starting the process of seeing him- or herself as a nurse through the teacher-learner relationship with the elderly client. The elderly client functions as an unofficial agent of socialization by legitimizing the student's role.4
"Some things are shocking and make me feel nervous" describes the temporary strain a student experiences during an encounter. The term "shocking" describes a response to seeing attributes of the client, such as body image changes and mental status decline, and hearing information on sensitive subjects (eg, death and sexuality).
"Some things make me feel nervous" suggests that students feel uncomfortable when they try to deal with the situation.
RECOMMENDATIONS TO NURSE EDUCATORS
"It is hard to say good-bye" illustrates the idea that students become attached to their clients, even in a short time.
The process of spending time with an older client who is helpful, caring, and interesting generates a closeness that makes the process of ending the encounter difficult.
Recommendations to Nurse Educators
This study is a preliminary attempt to uncover the meaning of an encounter between nursing students and their elderly clients. Knowledge of the students' views can assist nurse educators in identifying teaching strategies for preparing practitioners in gerontological nursing. The Table gives recommendations for planning clinical experiences for beginning baccalaureate students.
The use of narrative writing is a particularly effective strategy for clinical instruction. Following a client visit, students write about the encounter and the instructor responds, in writing, to the student. In this way, successes can be acknowledged and difficulties identified so that problem solving can begin. Any stress that occurred during the encounter could be mitigated by effective communication between the instructor and student. This strategy supports the recommendation by Karns and Schwab, who advocate a conscious employment of interactional skills to reduce stress in the clinical setting.11
Several other recommendations can be made based on this study. First, the findings suggest rules for students to follow during a home visit. These rules include:
1. Show interest in your client;
2. Listen to your client;
3. Anticipate all kinds of appearance;
4. Anticipate that some kinds of conversation may be anxiety provoking for you;
5. Consider using touch and reminiscence as ways of renewing your client's sense of being; and
6. Recognize that your visit may interrupt the process of "being alone."
Second, elderly clients appear to serve as unofficial legitimators to students beginning to develop their professional role. By their encouragement and positive criticism, they give support to students in their identification with the nursing role. Legitimation is an intriguing concept for further exploration by educators interested in student culture. Third, this study needs replication in other settings to examine further the students' views of home visits with elderly clients.
The reliability of the categories needs to be established through replication. Finally, the findings imply that older persons themselves can serve as role models in assisting students to recognize care-receiving behaviors.
- 1. Spradley J: The Ethnographic Interview. New York, Holt, Rinehart and Winston, 1979.
- 2. King PA, Cobb M: Learning to care. J Gerontol Nurs 1983; 9(5):288-292.
- 3. Mead GH: Mind, self, and society, in Boots CQ (ed): Standpoint of a Social Behaviorist. Chicago, University of Chicago Press, 1934.
- 4. Oleson VL, Whittaker EW: The Silent Dialogue. San Francisco, Jossey-Bass, Inc. 1968.
- 5. Leininger M: Transcultural Nursing. New York, John Wiley & Sons, 1978.
- 6. Leininger M: Transcultural Nursing - 1979. New York, MASSON International Nursing Publications, 1979.
- 7. Aamodt AM: The care components in a health and healing system, in Bauwens E (ed): The Anthropology of Health. St Louis, C-V. Mosby, 1978, pp 37-45.
- 8. Watson J: Nursing: The Philosophy and Science of Caring. Boston, Little, Brown, and Co, 1979.
- 9. Griffin AP: A philosophical analysis of caring in nursing. J Advanced Nurs 1983; 8:289.
- 10. Opler ME: Themes as dynamic forces in culture. Am J Sociology 1945; 51:198-206.
- 11. Karns PJ, Schwab TA: Therapeutic communication and clinical instruction. Nurs Outlook 1982; 30(1):41.
RECOMMENDATIONS TO NURSE EDUCATORS