A review of the literature since 1970 suggests a correlation between positive attitude formation among nursing students or practicing nurses and an increase in the number of nurses choosing to work with the elderly. This belief has repeatedly been refuted by studies that indicate no direct relationship between a positive attitude toward and willingness to work with the elderly.1-5 In addition, the number of educationally prepared nurses choosing gerontologie nursing as a specialty remains critically short of the desired levels.6 Thus, it is imperative for those of us involved in the development of future leaders and practitioners in nursing to reexamine past results in an effort to derive guidance for tomorrow. This article discusses how a literature search provided such guidance for the development of a gerontologie nursing elective in an effort to stimulate interest in caring for the elderly among baccalaureate nursing students.
Attitude may be defined as "a relatively enduring system of affective, evaluative reactions based on beliefs which have been learned about the characteristics of any object."7 Extrapolating from this definition, it may be seen that attitudes are both affective and cognitive responses to objects. Attitudes are based on experience with the object or similar objects. In addition, while attitudes may give rise to specific behaviors, they are not in and of themselves action producing.
The volume of literature verifies that nurses' attitudes toward the elderly are an important variable in providing quality patient care for this group.5,6,8 Goebel9 noted that "attitudes are a potential influence on interpersonal behaviors in situations where patients of all ages are dependent on caretakers. " As a group, the elderly are more independent on professional caretakers as a result of the increased number and frequency of chronic health problems, and the loosening of extended family networks. In addition, Penner, et al,10 stated that "studies of nurses who actually work with elderly patients suggest that nurses who hold negative attitudes toward them will engage in behaviors that may be detrimental to the best interests of these patients." Therefore, negative attitudes among medical professionals toward the elderly take on very serious implications for this growing patient population.
A few authors have identified positive attitudes among nursing students toward the aged.1113 Factors that contribute to this positive attitude formation include prior positive experiences with an elderly relative or friend, a positive attitude held by a faculty or staff member working with the elderly, and experiences working with healthy elderly living in the community.14 While role socialization may contribute to positive attitude formation among student nurses, studies continue to show a lack of willingness on the part of the students and practicing nurses to work with this age group, as well as persistent negative stereotypical attitudes.9,13'15 Additional factors that may facilitate an understanding of this response are individual perceptions as influenced by group norms and current role modeling within the field of gerontologie nursing.
An individual's perception of a given situation has been shown to consist of a variety of intervening factors, but perception is more than just the sum of these intervening variables. It is the result of an individual's unique ability to interpret and synthesize the incoming stimuli into his or her own personal view of the situation.
An important influence on a person's perception of an event is the learned normative expectancy. Dohrenwend and Dohrenwend16 stated that the impact of a specific event may be viewed in terms of group norms. What is held as positive or negative by the group will affect the perception of the individual. Garrett14 stated that a definite influence upon attitude formation toward care of the elderly is the view of the elderly held by contemporary society.
In this nation's recent past, advanced age received little or no worthwhile recognition. The America of the '60s and '70s had a strong youth orientation. Although the country's elderly population was growing rapidly, their visibility was amazingly low. Social disengagement theory was a widely supported method of assisting the elderly to accept the inevitability of old age and dying. Isolation of persons over 60 years of age in retirement communities and rest homes was the norm. Movements such as these reinforce among society attitudes that the elderly are not valued. From this point of view it follows, then, that those who work with the elderly are also not valued.
Currently, this trend has been reversing itself as evidenced by emphasis placed on the elderly via the White House Council on Aging, more elder statesmen being elected or appointed to national office, extension of the mandatory retirement age from 65 to 70 years, and the popularity of many elderly stars of stage and screen. This increased visibility of the elderly, and the statement this issue is making to society regarding the viability and importance of our older Americans may serve to influence group norms of the future.
Among nursing professionals, a trend that will have a positive impact on attitudes toward caring for the elderly is the emerging recognition of gerontologic nursing as a professional group. Programs of study in gerontological nursing are now available at the master's and doctoral levels with increasing levels of enrollment.14 Nurses specializing in the care of the elderly are being recognized for their expertise as they work with other healthcare professionals. As they intervene effectively in complex patient care problems, such as caring for the patient with Alzheimer's disease, they are demonstrating to physicians, social workers, and other professional groups that nursing has a significant contribution to make in the care of our nation's elderly.
As a group, gerontologie nurses may have more negative stereotypes to overcome; however, the demand for their specialized knowledge and skills as a result of the ever-increasing population of clients they serve will outweigh the forces that have, until now, inhibited their growth. In addition, with continued professional growth and increasing status of gerontologie nurses will come the much needed mentors and role models for students and practicing nurses to emulate.
Polarization of health care may also serve as an impetus to increasing interest in caring for the elderly. As a result of the diagnosis related groups (DRGs), an increasing number of elderly patients are projected to be discharged from acute care facilities into the community with more nursing care needs. This movement will create a renewed interest in nursing skills, rather than dependence on mechanization and the technical aspects that receive so much attention in the hospital setting. The nursing skills that set the professional nurse apart, such as the analytical and problem-solving abilities, interpersonal communication skills, and the ability to formulate nursing diagnosis and initiate independent interventions, will be highly sought.17,18 Given that the population of elderly persons is increasing and the vast majority of elderly persons live in their own homes, more and more nurses will be providing direct care to the elderly in the community. Furthermore, as more nurses become involved in the care of the elderly and gain recognition for their contributions to this care, attitudes toward this age group will be positively influenced.
The importance of a strong knowledge of the unique needs of the elderly as a basis for providing quality care cannot be overstated. Many researchers have found, however, that registered nurses, especially baccalaureate-prepared nurses, are unwilling to work with the elderly.6 Based on the educational preparation of this group, the baccalaureate nurse's focus with his or her patient is rehabilitative with the goal of attaining optimal health. In contrast, the perceived goal of care for the person confined to a long-term care facility is largely custodial.19 The dichotomy between these two goals of care may be responsible for the development of negative attitudes on the part of nurses during their first years of working with the elderly. Therefore, a course in gerontologie nursing should assist the student in recognizing and dealing with this dilemma. Students should be encouraged to use their nursing knowledge and skills creatively to address the health problems of the elderly in an effort to promote health maintenance and rehabilitation. In addition, with the present impact of diagnosis related groups, discharge planning must be an integral component of any curriculum dealing with the elderly. Nursing, a 24hour hospital service, is vital in the care of this largest segment of our population.
As nurses continue to seek opportunities to practice in an expanded role, the benefits of gerontologie nursing may become more attractive. Reif6 described the current situation of physicians being unwilling to be involved in the long-term aspects of caring for the geriatric client. This unwillingness on the part of physicians provides opportunities for clinical specialists and nurse practitioners educated in gerontologie nursing to attain autonomy, power, and influence. Without a gerontological knowledge base, nurses will have difficulty managing problems of the aged. Thus, nursing faculty in baccalaureate nursing programs are challenged to introduce students with a positive frame of reference to the newest of the clinical specialties - gerontologie nursing.
Based on the need to develop positive attitudes, change values, and think futuristically as advocates for the elderly, a course in gerontologie nursing was developed at a southern, statesupported, baccalaureate nursing program. The course was offered as an elective for senior generic nursing students. Before classes began, nurses currently working with the elderly in the community adult day-care centers were encouraged to audit the class. In the absence of a clinical component, the community representatives were expected to increase the student's awareness of current problems and lend validity to content presented in lecture.
The elective course, based on the objectives stated in the Figure, was approved for the summer of 1984. A total of eight generic baccalaureate students and two to three practicing registered nurses from the community attended the sessions. The didactic portion of the course lasted for two hours, and met three times per week for a total of eight weeks. The course consisted of lecture presentations by faculty and invited guests; field trips to nursing homes, adult day-care centers and retirement communities in the local area; and a panel discussion with representatives from area community agencies.
The course provided students with an opportunity to use their nursing knowledge and skills creatively with the *geriatric client. It was designed to build on existing knowledge and skills through identifying the physiological and psychological variables causing deviations in the health of older persons. Emphasis was placed on old age as a normal developmental process, attitudes toward the elderly as an influence to care, multiple chronic conditions that are frequently associated with the over-60 age group, and the development of a plan of care for the rehabilitation and maintenance of health. Identification of problems and appropriate intervention, vis-à-vis the nursing process, were covered through group presentations and written assignments. Field trips and clinical work were used to fulfill course requirements.
The students were graded on attendance (5%), results of two examinations (35%), one oral report (10%), and a formal paper (50%). Each student received a completed syllabus on the first day of class. Two books were required for the course and all books on aging in the medical center were placed on reserve for student use during the eight- week session.
Student and faculty rewards far outweighed the expectations of the course. The second class session provided the "aging experience" necessary for the students to appreciate the aging process. By playing the game Into Aging: A Simulation Game,20 students were transformed into aging roles while faculty assumed hostile, negative roles. This simulation experience mimicked current prejudicial attitudes toward the elderly and provided the framework on which much of the lecture content was based.
The first 15 minutes of each class session were devoted to an oral presentation. Students were asked to develop and either discuss or visually present their philosophy of aging. Two students presented conceptual models, using a roller coaster to represent the physical and psychological highs and lows of aging, and a ladder to depict significant life events that allow the person to grow or regress. Other students discussed older persons who had had a positive impact on their lives. One student developed a slide presentation of all the clients she worked with at a nursing home. Both students and faculty evaluated this course component positively. The students thought they had been challenged to do some soul-searching about aging and what it meant to them personally.
The creativity of the students was additionally challenged while they prepared an in-depth study on a topic of their choice. The guidelines were detailed in class, and faculty were accessible to the students to assist with selection of appropriate content and the literature review process. Students were required to hand in quality manuscripts with appropriate documentation and literature review. Examples of topics chosen by students included: "Acute Care and the Blind Elderly," "A Preschool Curriculum on Aging," "DRG Dilemma," "Alzheimer's Disease," "An Inservice Education Program: Sensory Deprivation," and "A Patient Study in Hypertension." Faculty assisted several students in submitting their papers for possible publication. This approach enhanced each student's role as a contributing member of the healthcare team.
Field trips were conducted during the semester to a variety of local agencies, including a long-term care facility, a geropsychiatric unit, a retirement center, and an adult day-care center. Students were able to interact with clients and staff. The strengths and weaknesses of each facility were discussed after the field trip, and students proposed recommendations for improving services provided clients in each area. As a result of course evaluations, a clinical component is being considered for future courses.
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