Our society believes that human beings have the right to know, to be informed, and to be taught. These rights are known as "the rights to well-being, or needs fulfillment rights."' These rights are demonstrated daily in our school systems, news media, informed consent procedures, and patient-teaching interactions. All too frequently, nurses do not regard these rights in an egalitarian manner across the life span of their patients.
Children and young and middle-aged adults are taught and informed. The elderly, however, are often perceived to be too oíd to Ìearn or incapable of understanding new information. The elderly, themselves, do not always agree with this assessment. A recent study of nursing home residents revealed that three fourths of the surveyed group responded that people are never too old to learn.2
Older adults, as consumers of health care, have the right to information concerning diagnosis, treatment, and prognosis in terms that can be understood.3 From a broader perspective, they also have the right to information that can be used to maximize health and prevent illness. To facilitate fulfillment of these rights, the nurse is legally and ethically bound to engage in health teaching in a manner appropriate to the learning needs and abilities of the elderly client.
The value placed on the elderly and the attitudes toward them reflect a society's level of cultural sophistication. In our high-tech society, the devaluation of the elderly continues the propagation of tenaciously held myths and stereotypes.
For many elderly, the social disdain and discriminatory practices purported by a particular culture become selffulfilling prophecies. "The elderly person is very aware of ageism, negative stereotypes and myths, and that he is frequently considered a burden on society even though he is competent. He may feel rejected, isolated, lowered self-esteem, anger, self-hate and dependent."4 The elderly most likely to have internalized these negative attitudes are those who are dependent or institutionalized.4-"7
The endowment of certain rights does not necessarily guarantee their fulfillment. The right to know requires corresponding access to information. Age-related changes in the client require modification of teaching strategies on the part of the nurse. It is possible, however, that negative stereotypes concerning the elderly and a lack of sound geranio I og i cal knowledge have prevented nurses from employing teaching strategies that would enhance elderly clients' knowledge and use of health-related information.
COMMON VARIABLES INFLUENCING LEARNING IN THE ELDERLY AND NURSING TEACHING TECHNIQUES
"Human aging is versatile and differential . Though universal in so far as all humans age, human aging exhibits great variation in direction, pace, effects, patterns, styles, interpretation, evaluation and management. "K Therefore, age-related variables become the emerging common denominators that prompt modification of teaching-learning strategies.
Aging is a normal universal phenomenon accompanied by a series of décrémentai changes and complex body system interactions that ultimately affect the teaching-learning process. Although these changes are universal, they are unique to each individual in terms of their onset, intensity, patterns, and manifestations.
Intellectual functioning does not deteriorate automatically with chronologically advanced years; old age is not synonymous with declining intellect. Learning is dynamic and fluid and is a shared, lifelong event. Regardless of the type of learning or the age group to be taught, learning takes place over time. The total process of learning and remembering includes apprehending (registering the stimulus, attending, perceiving, coding), acquiring (relevancy and idiosyncratic coding), and storing and retrieving (recall and transfer of intellectual skills),9 Significant variables influencing the learning process are age-related alterations in sensory perception, motivation, response time, sleep- wake cycles, and memory.
A major factor in the learning process is the perception of the stimulus by the learner's sensory system. For learning to take place, the stimulus must be perceived by the senses, primarily vision and hearing, be interpreted or attended by the learner, briefly stored and coded in primary memory, and then stored in secondary memory. Visual and auditory response acuities decline with age, thus generating stimuli identification and discrimination problems.10
Motivation, task meaningfulness, and task familiarity also affect the older client's ability to respond to new learning stimuli. The more meaningful the task, the higher the motivation to perfo well." Information that is familiar, meaningful, or relevant to the learner tends to be processed more deeply by both young and old alike, but older persons seem to be affected disproportionately by task meaningfulness. 1244
Inherent in motivational impetus are the factors of cautiousness and risk taking. As people grow older they become more resistant to risk taking and become increasingly more cautious.
As a result, the elderly are less likely to attempt a response to a new learning stimulus unless they are relatively certain that it will be correct. 12.15.16 Schuster and Ashburn suggest "that the tendency toward increasing cautiousness with age is, in and of itself, a reflection of a deeper motivational restructuring of the personality."'2 Filer and O'Donnell found that elderly within institutions generally functioned way below their capacity; however, their functional level rose dramatically when they were exposed to greater opportunities for involvement or learning, when expectation levels were increased, and when greater attention was allotted them.17
Reaction and response times increase from about age 20. These increases intensify after age 60; thus the elderly are at a disadvantage when pressed with complex tasks to be performed under constraints of time.'2"82? Performance becomes more congruent with those of younger age groups when the determinant of time is eradicated)2'2''22
Another determinant in the teachinglearning process is related to sleepwake cycles and fatigue. The quality of sleep and wakefulness changes with advancing years. The polycyclic pattern of the sleep-wake cycle becomes more fragmented with age 23 Frequent rest periods are appropriate for maintenance of energy reserve toward task achievement.
The literature distinguishes two types of memory: primary and secondary. The establishment of a memory trace involves three stages: input, coding, and storage. The input of information is accomplished through the senses. The coding of the information takes place in primary memory.
Here the data is rehearsed and transformed into smaller pieces, which can be compared with previously learned data and stored more easily in secondary memory.12,24 The major source of age-related deficits resides within the original encoding process. The rate of input influences the probability of coding and transfer. The slower the rate of input, the higher the probability of coding and transfer. 25
Information is stored in and retrieved from secondary memory. To facilitate retrieval, data must be organized efficiently and stored with a retrieval plan or cue so that when information is required the learner knows where to search for it. Disorganization is one block to information retrieval. An additional cause of memory failure lies in ineffective retrieval plans or cues. By developing an understanding of this process, the nurse can therapeutically manipulate the coding and transfer process.
These multiple, complex, and often subtle changes that accompany aging provide scientific rationales, previously unavailable, for the formulation of gerontological nursing teaching strategies.
Guidelines to Facilitate Optimal Learning
Nurses have long been aware of the common physiological, age-related changes in vision and hearing, and the environmental manipulation required to create an optimal learning environment.26 In addition to the standard modifications to mediate light, sound, activity, size, and physical safety of the learning arena, deliberate nursing actions based on individualized client assessment must be directed toward the interpersonal environment and the elements of instructional design (see Figure 1).
A BASIC GERONTOLOGICAL TEACHING-LEARNING MODEL FOR NURSING
An environment that affords psychological safety and a sense of security established through respect and acceptance, and that is devoid of impatience and ridicule is crucial to the learning process. Nursing actions that convey optimistic expectancy, calm certainty, and praise can create an environment in which the client feels capable of success, free to take risks, and motivated to explore new learning tasks. The establishment of highly personalized, clientcentered goals that are mutually generated increases participation and task meaningfulness. This is particularly important for those elderly who experience anxiety or depression, alterations that reduce drive and incentive.27
Edinberg recommends "reducing autonomie arousal (anxiety)."28 Autonomie arousal can be reduced by ensuring privacy, comfort, rapport, and maintaining familiar schedules. Moderation of arousal and relaxation techniques prior to the learning task facilitate psychological safety, decrease anxiety, and maximize client capacity to apprehend and acquire presented information.
Client variables related to response time, sleep-wake cycles, and memory require judicious structuring of the elements in the instructional design. Compensation for increased response time can be made by decreasing the rate and amount of information presented, and by increasing the length of time provided for learning sequences.28 In addition, organizing tasks and materials into smaller units - serial learning - enhances not only perceiving and acquiring but the coding and storing of information.
Energy levels may be depleted due to age-related alterations in sleep-wake cycles. Using these teaching techniques prevents bombardment of content and minimizes client fatigue. Provision for short rest periods or naps can also greatly restore energy and enhance the concentration for learning.29
Many strategies exist to facilitate memory, specifically in the area of coding and retrieval from storage. Recitation helps sustain attention and reinforcement. Equally useful is periodic review to keep information current. Overlearning to achieve habituation increases retention over time.30 Increasing the usefulness or meaningfulness of material allows the learner to form associations between new information and that which was learned previously.
Establishing a retrieval plan that consists of one or several cues helps bring forth learned material from secondary memory. Retrieval cues are associative devices that trigger images of a highly relevant nature and personalize the experience for the client. For example, an experienced driver requiring flexion and extension foot exercises could use associative cues imaging accelerating and releasing a car's gas pedal. These intervention strategies require a highly individualized approach on the part of the nurse.
The various elements of the instructional design are highly interrelated and contribute to the overall effectiveness of the process. The scientific rationale for gerontological teaching strategies are rooted not only in the knowledge of age-related changes but in the phases of the learning process (see Figure 2).
The capacity to learn is a lifelong capacity, even though a multitude of factors may encroach on the individual because of normal age-related changes. We must not "regard the elderly as passive victims of a cognitive degeneration of which they are helplessly aware."12 Instead, we must suspend youth-oriented attitudes and standards against which the elderly are measured, and establish those standards and goals that are age-appropriate and ensure the fulfillment of the right to know.
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