Developing a clinical experience in a nursing home for students of nursing is a logical response to the projections of rapid growth in the frail elderly population, and to the increasing need for professional nurses in long-term care. WallMass et al,1 King et al,2 Langland,3 Gass,4 and others have suggested that both beginning and advanced nursing students couid improve clinical skills and develop positive interest and abilities while caring for the elderly client in the nursing home setting. The nursing home offers a diversity of learning experiences. These include working with individuals and groups of residents, and assuming leadership rotes in the facility. University collaboration with nursing homes that function as teaching and research sites has been a focus of the Robert Wood Johnson Teaching Nursing Home program.5-6
THE NURSING HOME AS A CLINICAL SETTING FOR COMMUNITY AND MENTAL HEALTH NURSING
As a part of a grant, funded by the Department of Health and Human Services, designed to prepare and interest nurses in careers in long-term care, the school of nursing at the University of Massachusetts at Boston, the division of nursing at the University of Massachusetts in Amherst, and the Massachusetts Long Term Care Foundation are developing materials to facilitate the mutual sharing between schools of nursing and long-term care facilities. Working with the Long-Term Care Foundation, the research and educational arm of the Massachusetts Federation of Nursing Homes, makes it possible to gather the ideas and disseminate information to interested nursing homes and schools of nursing throughout the commonwealth and elsewhere. This report of grant activities is written by a professor, the associate dean of academic affairs at the university, the director of nursing, and by the director of community relations of one of the nursing homes designated as a clinical site for the grant period. The faculty member in the school of nursing serves as the grant's principal investigator.
Neponset Hall/Ashmont Manor is a 175-bed, Level III facility located in metropolitan Boston. The facility was selected prior to the grant period to participate in a trial program with beginning students in foundations of nursing.
Although faculty and nursing home staff were familiar with other similar programs through the literature, it was a new experience for both groups. This experience was favorable enough for students, faculty, residents, and the staff of the nursing home to encourage continuation through the grant period and to explore other possibilities of university school of nursing and nursing home collaboration.
The philosophy of the administratorowner and his management staff that made Neponset Hall/Ashmont Manor an ideal site for university linkage was that, "Nursing homes should have an important role in developing strategies for a better health-care system for the elderly. Working with the university is an excellent way to begin the process. " The nursing home staff and university faculty met together to discuss their individual and joint goals.
The school of nursing wished to continue its educational program at the nursing home as a senior level clinical experience in community and mental health nursing. This goal at first was met with skepticism by other faculty and students. How could the nursing home be considered an adequate site for developing an understanding of community issues in health care and developing skills in mental health nursing?
The primary objective of the nursing home was to enhance the quality of life and improve the quality of care delivered to the elderly residents. The nursing home sought to solidify the relationship with the academic community, to foster the development of positive attitudes of student nurses toward gerontological nursing, and to actively participate with the community at large. Although the congruence of the school of nursing and the nursing home's objectives was unexpected, hammering out the details was a process involving great commitment of energy and resources. (Objectives are outlined in Figure 1.)
Students enrolled in the senior-level course in family and community health nursing are assigned to the nursing home by the university for two full clinical days a week during the entire first semester of their senior year. The theoretical component of this course, which focuses on community and mental health nursing, includes content addressing the psychosocial and physiological needs of the frail elderly, and is presented by school of nursing faculty members. Students are introduced to the nursing home's philosophy and practice of long-term care by the director of nursing and the director of community relations.
Clinical learning is directed toward three separate but interrelated areas: resident assignments, agency projects, and community assessment.
Resident Assignments: The nursing home staff identifies clients who may be assigned to students. Criteria for selection are willingness to participate, ability to make informed decisions, and absence of serious termination issues; that is, the client would not suffer severe loss when the student completes the clinical placement. The resident should have physical and psychosocial needs that would benefit from student intervention and would meet student learning needs. Clients who agree to participate in the project sign a consent form (Figure 2).
The students provide appropriate physical and emotional care to the resident and serve as the primary nurses on the two days a week they spend in the nursing home. They participate in the daily routine of the agency, interacting with all levels of care providers, and participating as full members of the multidisciplinary team. Students and residents work closely together over the course of the semester, and develop a close relationship. Supervision on the mental health model enables the student to examine the nature of the one-toone relationship with a frail elder, many of whom have physical and mental health problems including depression and chronic mental illness.
Agency Projects: The university faculty and the nursing home staff develop projects for students in the areas of education, therapeutic intervention, and community exploration, all important aspects of the provision of quality longterm care services. They assist the students in identifying their learning needs and assign projects based on student interests and compatibility with agency needs. Project supervisors are members of the facility management staff who volunteer to participate in teaching and supervising the student throughout the semester. Projects may vary from semester to semester (Figure 3).
The nursing home considers the education of both staff and residents to be of primary importance in achieving the goal of quality care. Students are able to further this goal through their project activities. Examples of projects that students have completed include:
1) Staff Development: Under the supervision of the director of staff development, students assist by teaching basic nursing skills including orientation and certification programs for nursing assistants.
CLIENT CONSENT FORM
2) Consumer Awareness/Quality Assurance: Under the supervision of the QA coordinator, the student attends QA meetings, completes audits, and presents findings.
3) Resident Education/ Drug Awareness: Students gain experience in teaching about medication usage and side effects through working with a small group of residents.
4) The Resident/Physician relationship: Students and the nurse practitioner work with residents to develop an improved rapport with their physician. The goal is to improve the frail elder's autonomy.
Students assist in the planning and facilitation of goal-oriented therapeutic groups. The director of recreation and volunteers works with students in the development of a resident "buddy system," a program designed to aid in the adjustment of residents to nursing home environment.
An experienced resident can be of great assistance to a new person entering the nursing home. The student's role is to select residents who have successfully adjusted to the nursing home and train them to provide information and support to new people. Other student projects include reminiscence/life review, pet therapy, music therapy, exercise, socialization, and remotivation groups. The variety of projects is limited only by the imagination of students and staff commitment to continue successful projects once that semester's students have left.
Community Assessment: Although nursing home residents may appear to be isolated within facility walls, they are indeed a part of the larger community. Student participation in community projects reinforces the concept that nursing homes are part of the continuum of health-care services. Working closely with the director of community relations, students explore neighborhood service agencies and determine strategies for resident involvement. The project involves linking residents with community agencies as a step toward increased independence, improved self-esteem, and possible discharge. A rotating assignment gives students an opportunity to participate in preadmission screening and discharge planning processes. Visits to a variety of service agencies in the community broaden the students' understanding of the role of the RN working in a community setting. Whenever possible, students visit elderly clients in their homes with a visiting nurse.
To fully develop the myriad of healthcare services that will be required by the elderly in the near future, hospitals, universities, and long-term care facilities must combine their skills and knowledge. Through this grant, the University of Massachusetts at Boston 's School of Nursing, Neponset Hall/ Ashmont Manor, and other cooperating agencies have begun that process. In the nursing home setting, the students function as professional nurses who are patient-care planners, managers, and facilitators of therapeutic intervention for enhancement of quality of life for the elderly nursing home resident. The nursing home community gains as much from the experience as the students. Residents look forward to the days the students will be in the nursing home. For the staff, the integration of students into the facility means positive change and participation in the community. The students' involvement enables nursing home staff to enhance existing programs and to develop new methods of meeting resident needs. As stated by the director of nursing, "It is very exciting for us to be part of the educational process and to effect change. We are participating in the future of health care in Boston."
AGENCY PROJECT OUTLINE University of Massachusetts/Boston Ashmont Manor/Neponset Hall Community Health Placement
- I . Wall-Haas C, Bahista L, Stecchi J, et al: Nursing home placement for beginning baccalaureate nursing students - Why not? Journal (if Long Term Cure Administration. Winter 1983 , pp 3-6.
- 2. King P: Learning to care. J Geranio! Nurs 1983; 9(5):289-293.
- 3. Langland RM: Change in basic nursing student attitude toward the elderly after a nursing home experience. J Nurs Ed 1986; 25(1): 31-33.
- 4. Gass K, Tarr J: Diverse learning experiences from a nursing home clinical. J GerontolNurs 1986; 12(6):27-30.
- 5. Lynaugh J, Mezey M, Aiken L, et al: The teaching nursing home: Bringing together the best. American Health Care Association Journal 1984; 24-28.
- 6. Burke M, Donley R: The educational experiment - A teaching nursing home. J Gerontol Nurs 1987; I7(l):36-40.