Journal of Gerontological Nursing

Including Gerontological Nursing in Graduate Nursing Curriculum

Debra C Davis, RN, DSN

Abstract

As the population over the age of 65 increases, the demand for nurses prepared to care for the specialized needs of this group also continues to grow. Multiple options for health care dictate that nurses must be able to function in many different settings with older adults. Traditional employment sites, such as hospitals, continue to have an increasing demand for nurses, and the market for nurses in home health care, nursing homes, community health, ambulatory clinics, and retirement centers continues to expand.

Well-prepared nurses who are knowledgeable and skilled in gerontological nursing are increasingly being recruited to nil both vacant and newly created positions. Because of the growth and new directions occurring and envisioned in gerontological nursing, educational programs are challenged to prepare graduates who are on the cutting edge of new developments and innovations in the field. Nursing programs must structure learning experiences for future nurses that develop the philosophy that life continues to have meaning in old age, and that will result in more nurses making a career choice of working with older individuals.1

The way in which one baccalaureate program is accomplishing this task was published in the Journal of Gerontological Nursing.2 Collins and Brown described the project and discussed common academic and student obstacles that nurse faculty must address as they revise their school's curriculum. The next phase in the educational process - graduate nursing education - is examined in this article. Briefly discussed here are the multiple approaches currently being used by master's programs in nursing to structure their curricula and to decide what content to include. An example of how one graduate nursing program is incorporating gerontological nursing content in the advanced adult health nursing major is shared.

BACKGROUND

According to the American Nurses' Association, graduate programs in nursing prepare graduates for advanced practice in a specialized area of nursing.3 Master's prepared nurses practice in a variety of settings, provide leadership, and initiate collaborative and consultative relationships for the purpose of improving nursing and health care. The master's program builds on the baccalaureate degree in nursing and provides a foundation for doctoral study.

Graduate students vary widely in their abilities to conduct a comprehensive assessment and to recognize agerelated changes. This activity can be repeated in whole or in part by students who need to improve their assessment skills.

Another aspect of assessment required of the students is performing a functional assessment. Many of the students have never conducted a functional assessment. Students are provided with several different functional assessment tools. For example, Lawton's Physical Self-Maintenance Scale, and the Residential Functional Assessment Scale of the Jewish Center for the Aged are reviewed. Once students obtain the data for the functional assessment, the data are analyzed. Students discuss how their nursing practice decisions were influenced by the findings (Table 3).

My client, although quite frail at age 86, scored well on the functional assessment tool. My goals are to initiate measures to sustain her functional abilities. I have encouraged her daughter to allow her to do as much for herself as she can. We've discussed adding handrails in the shower area to make bathing easier and safer. Because Mrs G's daughter tends to be overprotective, we've discussed the importance of allowing Mrs G to continue to participate in household duties.

My client suffered a stroke and was left with left-sided weakness, lhe physical self-maintenance scale reveals that Mr C has limited functional abilities but can feed, dress, ambulate, and bathe himself with assistance. According to the SPMSQ, his intellectual functioning is intact. Therefore, Mr C will be actively encouraged to participate in all selfcare activities,…

As the population over the age of 65 increases, the demand for nurses prepared to care for the specialized needs of this group also continues to grow. Multiple options for health care dictate that nurses must be able to function in many different settings with older adults. Traditional employment sites, such as hospitals, continue to have an increasing demand for nurses, and the market for nurses in home health care, nursing homes, community health, ambulatory clinics, and retirement centers continues to expand.

Well-prepared nurses who are knowledgeable and skilled in gerontological nursing are increasingly being recruited to nil both vacant and newly created positions. Because of the growth and new directions occurring and envisioned in gerontological nursing, educational programs are challenged to prepare graduates who are on the cutting edge of new developments and innovations in the field. Nursing programs must structure learning experiences for future nurses that develop the philosophy that life continues to have meaning in old age, and that will result in more nurses making a career choice of working with older individuals.1

The way in which one baccalaureate program is accomplishing this task was published in the Journal of Gerontological Nursing.2 Collins and Brown described the project and discussed common academic and student obstacles that nurse faculty must address as they revise their school's curriculum. The next phase in the educational process - graduate nursing education - is examined in this article. Briefly discussed here are the multiple approaches currently being used by master's programs in nursing to structure their curricula and to decide what content to include. An example of how one graduate nursing program is incorporating gerontological nursing content in the advanced adult health nursing major is shared.

BACKGROUND

According to the American Nurses' Association, graduate programs in nursing prepare graduates for advanced practice in a specialized area of nursing.3 Master's prepared nurses practice in a variety of settings, provide leadership, and initiate collaborative and consultative relationships for the purpose of improving nursing and health care. The master's program builds on the baccalaureate degree in nursing and provides a foundation for doctoral study.

FIGUREINCREMENTAL MODEL

FIGURE

INCREMENTAL MODEL

Master's degree programs in nursing have doubled in the past 10 years, and although undergraduate enrollments are declining, enrollments in graduate nursing programs continue, to date, to do well. The proliferation of graduate programs is characterized by a wide variation in structure, length, content, and emphasis, including such basics as degree requirements and degree titles.4-5

Gerontological nursing may or may not be offered by a particular master's program, and the schools that do offer the content do so in a variety of ways. Some schools offer a clinical major in the field, preparing gerontological nurse specialists or gerontological nurse practitioners. Although the number of schools offering a major in gerontological nursing is increasing, in the past such programs suffered from low student enrollments. Low student interest, compounded by the difficulty of finding qualified faculty to teach in the area, resulted in gerontological nursing being viewed by many schools as a nonviable offering.6 With the increasing focus in our society on aging, and an expansion in the market for gerontological nurse specialists, more schools may be able to support a major in gerontological nursing in the future.

Some schools without a major in gerontological nursing accommodate students interested in the field by allowing them to subspecialize in gerontological nursing within the students' particular clinical major. Other schools may incorporate gerontological nursing content into selected clinical majors, but do not provide students with the opportunity to subspecialize in the field. Whether content on aging is incorporated into a clinical major or not depends on the philosophy of the program. However, the inclusion of gerontological nursing content reflects that many schools recognize the need for basic knowledge of gerontology in clinical majors such as adult health (or medical-surgical nursing of adults), mental health, and community health nursing, as well as in many other areas.7

The extent to which a student can subspecialize in gerontological nursing depends on the focus of the master's program. Reed and Huffman8 described two basic types of foci of graduate programs - clinical specialist programs and advanced generalist programs. Clinical specialist programs prepare graduates for advanced practice in circumscribed settings with readily identifiable client populations having delineated health-care concerns. The clinical specialist has an in-depth knowledge in the specialty area and would seek consultation for comprehensive care. For example, the clinical specialist student in adult health nursing often selects a subspecialty area of adult health on which to focus during graduate studies. Because adult health nursing can be defined as including all health-related needs and concerns of the adult population, students specialize in a small component of the "waterfront" that comprises adult health. If the student is not interested in gerontological nursing, the student may have very limited theoretical and clinical exposure to aging.

In contrast to clinical specialist programs, advanced generalist programs are characterized by breadth of knowledge in the field. The graduate is prepared to meet the diverse health concerns of a diffuse client population in a variety of settings. The advanced generalist responds to holistic health concerns, engages in a comprehensive approach to care, and would need to seek consultation from a specialist regarding the biopsychosocial subsystems.8 An adult health nursing major having an advanced generalist approach would not require students to subspecialize. Rather, the program goal would be to prepare students for advanced practice in all areas of adult health or, in other words, to cover the "waterfront." In such programs, gerontology is important content and may be covered in a variety of ways. For example, the health-care needs and concerns of young, middle-aged, and older adults or acute and long-term nursing care of adults could be used as curricular schemes.

The question of appropriate content in nursing curricula, especially at the graduate level, is one of debate. Appropriate content to include in the master's program related to gerontological nursing is also controversial. In theory, master's curricula builds on the baccalaureate base. However, baccalaureate curricula are not standardized, and therefore students come to the master's program with a wide range of knowledge and competencies in gerontological nursing.7

The Incremental Model has been proposed for assisting faculty to decide appropriate content for each educational level (Figure).9 The model depicts an educational ladder with a corresponding competency hierarchy.

Using this model, a baccalaureate curriculum should include content basic to gerontological nursing, such as normal aging changes, nursing measures to promote wellness, and adaptation to illness. Myths and stereotypes and ageism should also be addressed. The nurse generalist should be prepared to initiate interventions and to refer clients to the next level of professional nurse - master's prepared - as needed.

Gerontological nursing content in the graduate program should include in-depth content related to both normal and pathological aging processes. Issues in health care for older adults and health-care policy applications should be addressed. Then, at the doctoral level, the goal of education is to prepare researchers and theoreticians in gerontological nursing.

A GRADUATE LEVEL COURSE IN CERONTOLOGICAL NURSING

The adult health nursing clinical major at Troy State University, Montgomery, Alabama, fits Reed and Hoffman's advanced generalist definition.8 Students spend three quarters in the adult health major, which includes theory and clinical components. During the first quarter, students are exposed to the role of the advanced generalist. The role is referred to as a "nursing specialist," and in class a distinction is made between the nurse specialist and clinical nurse specialist roles. Students study theories and concepts essential to role enactment including, but not limited to, role, change, learning, and decision-making theories.

During the second quarter of Advanced Adult Health Nursing, students enroll in Advanced Acute Care Nursing of Adults. The focus of this course is advanced nursing care of adults in acute care situations. Students analyze the acute care health system and explore issues and trends, concepts, theories, and current research applicable to nursing care of adults with acute care needs.

Table

TABLE 1COURSE TOPICAL OUTLINE

TABLE 1

COURSE TOPICAL OUTLINE

The third and final quarter of adult health nursing is spent studying gerontology and the long-term health-care system as it relates to provision of services for older persons. Although long-term care is not synonymous with gerontological nursing, knowledge of the long-term health-care system is essential for the nursing specialist in gerontology. Long-term care is defined as a continuum of inter-related health and social services, which encompasses institutional and noninstitutional services and requires coordination of public policies, funding, and case management to provide appropriate options for people whose needs change over time.10

Three hours a week for 10 weeks are spent in class covering the course content. Students spend 6 hours a week for 10 weeks developing and refining decision-making, planning, and psychomotor skills during the concurrent clinical practicum.

Role of the Gerontological Nurse Specialist

The course objective is to prepare graduate students to meet the highly specialized health-care needs of older adults. To achieve this objective, course content includes both generalized and specialized information on gerontological nursing (Table 1). The course begins with a detailed examination of the role of the gerontological nursing specialist. The components of the role, which include clinician, educatoi; administrator, researcher, and consultant, are analyzed. Students review the standards of practice for gerontological nursing and consider the implications of aging for the nursing process. In other words, the ways in which obtaining a history and physical assessment on an older person would be different from a younger person, which physical assessment findings are considered pathological versus a normal age-related change, and how teaching and counseling with older persons might be different from teaching and counseling with younger persons.

Students are also exposed to a variety of functional assessment and mental status assessment tools. The importance of a comprehensive assessment that includes functional ability, assessment of the client's environment, and mental status are stressed. Content on theories and concepts of special concern to gerontological nursing is covered in depth. Topics such as social support, chronicity, coping with chronic illness, hospice, and compliance to a therapeutic regimen are examined and applied to the gerontological client. Additionally, current therapies and research on selected common health-care problems of older persons are studied. Topics covered include falls, sensory deficits, chronic pain, nutritional needs, sexuality, polypharmacy, cognition and confusion, and problems with elimination. Students quickly realize that much of nursing care is based on tradition or research provided by other disciplines rather than from nursing research.

Issues and Trends

An important objective of the course is for the students to be conversant with the major issues and trends in gerontological nursing and in the longterm health-care sector. The demographics of aging, developmental tasks, myths and stereotypes, and theories of aging are covered. Issues concerning funding for long-term care, policy issues related to aging, legal aid and advocacy, elder abuse, and research issues are also addressed in the course.

One of the most successful classes in the course concerns this particular objective. Representatives from several different public agencies that provide services for older adults participate in a panel discussion for the class. Representatives from Social Security, Medicaid, Adult Protective Services, the Long-Term Care Division and Division of Licensure and Certification of the State Department of Public Health, and the Commission on Aging are invited. Each representative briefly presents the services offered by their agency and describes how one qualifies for services. Students then engage the speakers in a discussion. The reactions of the agency representatives to the class have been positive, and many of the representatives return each year.

Into Aging

To challenge the student's affective development, an adapted version of the game, Into Aging is played.11 The purpose of the game is to simulate the experience of an older person going from an independent lifestyle to a dependent care situation. The game begins by having students compute their liiè expectancy and then subtracting 3 years. This then becomes the age of the student during the game. Students are provided blank stickers and asked to write the following on a sucker: the name they want to be called when they are old; six favorite possessions; six self-identity items; their occupation; and type of dwelling. Students then wear the stickers on their clothing and, in turn, role plays their new identities to the class.

The actual game is played in the nursing lab with three stations. Station one represents independent living; station two, semi-independent living; and station three, dependent living. Students begin the game at the first station by drawing situation cards. The cards graphically depict situations that prompt an individual to require assistive living. At stations one and two, students gradually lose their selfidentity, dwelling, occupation, and favorite possession stickers. Eventually, the majority of the students end up at station three, where a substandard nursing home situation is simulated: patients (students) are referred to as "Honey" or "Pops"; those who have drawn situation cards that say that they are senile are treated as such; and those who are described as incontinent on a situation card are restrained on a potty chair. Finally, one section of the lab is reserved for the cemetery, because, just as in real life, older people do die.

Table

TABLE 2REVIEW OF RESEARCH ACTIVITY

TABLE 2

REVIEW OF RESEARCH ACTIVITY

After the game is played, the class discusses the experience. Students readily share the frustrations they felt in losing their independent status. They also discuss feeling that they had to continually fight to regain a sense of self while in the nursing home. Many share that drawing a card to go to the cemetery was a relief For instance, one student stated: "I really got into the game and felt angry with the condescending way I was treated in the nursing home. I felt a sense of isolation and helplessness. I guess I've never really thought about old people having those feelings." The discussion is then led so that the students apply what they experienced during the game to actual nursing care situations with older adults.

Playing the game requires planning time to acquire all the items needed. Extra faculty are also needed to work at each station. However, the benefits in facilitating student discussion have made the effort worthwhile. Students continue to rate the activity as beneficial on course evaluations.

COURSE REQUIREMENTS

The course has three requirements: students develop a review of nursing research paper, prepare a class presentation, and conduct a life review of an older adult. To complete the review of research assignment, students are assigned to groups and to one of the health-care problems covered in the course. Students work in groups to locate nursing research studies on their assigned topic, analyze the studies, and write a report (Table 2).

Students initially are overwhelmed by the assignment, but soon actively pursue completing the task. The most frustrating aspect for students is locating research articles that can be classified as nursing research. The outcome of the activity is that the students appreciate the need for greater efforts in developing a research base for gerontological nursing. Another outcome is that students are able to incorporate the research recommendations into their clinical practicums.

Building on the review of research activity, the students work together to prepare a presentation for the class on their selected topic. This activity helps to build the graduate student's teaching skills and confidence in presenting to a group. The presentation is organized according to the implications of the problem for the gerontological client (eg, incidence, morbidity and mortality, and quality of life issues); advanced nursing care (eg, assessment guidelines, research- or nonresearchbased nursing interventions, and evaluation modalities); and recommendations for nursing research (eg, summaries of current status of knowledge and of areas still needing research).

Another course requirement that has been exceedingly beneficial to the students is conducting a life review of an older adult. The life review concept as presented by Butler is discussed in class as a naturally occurring universal mental process.12 By engaging in the life review process, older people are able to continue personal integration and increase their self-awareness. Butler refers to the process as consisting of reminiscence, thinking about oneself, and reconsideration of previous experiences and their meaning.

The goal of the assignment is to provide students an initial experience in conducting a life review. Outcomes of the activity are that the students can identify techniques for eliciting a life review, including special interventions that must be initiated to compensate for any physical impairments that the clients may have, such as hearing loss or decrease in visual acuity. The thrust of the life review, however, is for the students to analyze their own attitudes and feelings concerning the aging process.

To conduct the life reviews, the students guide the older person through their personal memories by using open-ended questions such as "What was life like for you as a child?" "How many brothers and sisters did you have?" Personal photographs, memorabilia, and questioning along a time line of major historical events are used as techniques to elicit the life review. Students are instructed that although the life review process is not considered a risky procedure,13 care must be taken to delicately set the stage. Some older persons may experience negative feelings about the content of their memories. With this in mind, the students select individuals to interview who appear to be welladjusted and who are not suffering from cognitive impairments. Typically, the subjects are not institutionalized, but occasionally will be a nursing home resident that the student has been seeing. Some students select family members or neighbors to interview.

All of the life review papers are exceedingly interesting to read and are often heart-warming. The students often convey that the experience was meaningful for them. Many of the students report that the life review assignment broadened their perspective and changed their attitudes on aging. For some, the activity helped them to understand the resiliency that they have observed in many older persons. Because of lifelong experiences with both positive and tragic events, many older persons have learned how to adapt and cope.

The following excerpts are from student papers:

The completion of this paper represents the single most exciting writing project that I have yet undertaken. The knowledge gained and thus recorded within these pages is extremely important to me. However, the experience has been an emotional one, and at times these pages have been damp with my tears. I do not have any illusions that this article is a literary masterpiece, but it is a tributes to someone that 1 love very dearly. . . my ferner.

One of the things I learned about myself through this interview is that I tend to stereotype certain people. In this instance, Catholic nuns or, more accurately, older Catholic nuns. Sister is as concerned, and may be even more involved in, today's problems than many younger people. 1 found myself thinking about what growing old means to me and what I want it to be like. What values will I maintain at that period of my life? This interview made me think about a lot of things. Not only did I learn how aging has affected this unique individual, but also that I want to always look at my own life and continue to ask myself "what else can I do?" I may end up with dentures, gray hair, and a million wrinkles, but I always want to give something back.

Course objectives are measured by evaluating the presentation, review of research paper, the life review paper, and a final examination. The examination is typically comprised of multiple choice, short answer, and an essay question.

CLINICAL REQUIREMENTS

Concurrent with the theory course, students spend 6 hours a week for 10 weeks engaged in clinical learning. The clinical practice requirements are modeled after the theory course content and are designed to assist the graduate student fulfill the course objectives and personal learning objectives. Some learning activities are required of all students (Table 3X others are optional (Table 4) based on the course grade that the student wants to achieve. Each activity is assigned points. To achieve a "B" or better in fte course, required activities plus a number of optional activities must be completed. The learning activities can be individualized according to the students' particular interests and learning needs.

Each student is assigned a preceptor and a practicum site where there are opportunities to care for older adults. Students have been assigned to a variety of clinical agencies, such as nursing homes, rehabilitation centers, hospice organizations, and home health agencies. In addition to the primary practicum site, students are required to visit two additional sites that provide services for older adults. These include adult day care centers, senior citizen centers, and nutritional centers. All students are required to make at least one visit to a nursing home. Students complete the assigned clinical activities and record their experiences in a journal. The journal is an important learning tool because each entry requires that the students critically evaluate their clinical experiences. The journal and completed clinical assignments are submitted to faculty each week for review and feedback.

Students report that the assignments help them synthesize course materials. They enjoy working with older adults and the nursing staff at the practicum sites. The first clinical assignment (to explore the concepts of chronicity, social support, coping, hospice, and compliance with selected clients) enables the students to compare actual client situations and experiences with the theoretical accounts discussed in class. Students learn firsthand what it means to have a chronic illness or to cope with living in a nursing home. Students include family members in their interviews to ascertain their perceptions, also. The interview data are then compared and contrasted to the Ii terature on the topic. Students discuss their analyses in their journals (Table 3).

An important aspect of the clinical practicum is for students to gain experience implementing the role of the nursing specialist with older adults (Table 3). Students select clients to work with who are experiencing problems related to the content covered in class. The students conduct nursing assessments of their clients using an assessment format that is consistent with a nursing model. The students may choose any nursing model, but the most popular models chosen are the Roy Adaptation Model, Orem's Self-Care Model for Nursing, or the Neuman Systems Model. Following the assessment, students develop a plan of care for their clients and incorporate nursing research when applicable. Students then work with and through the staff to implement and evaluate the care. One student recorded the following experience in her journal:

I was able to identity Mrs B's universal, developmental, and health deviation self-care requisites after conducting a complete physical, functional, and psychosocial assessment and retrieving significant objective data from the medical record. I then formulated nursing diagnoses and designed an individualized plan of care. I found the staff members receptive to the plan of care. Mrs B and her daughters were also included, and we discussed mutual goals. The plan is being implemented by the nursing staff and Mrs B's progress will be evaluated in 1 month.

Table

TABLE 3REQUIRED CLINICAL ACTIVITIES

TABLE 3

REQUIRED CLINICAL ACTIVITIES

The students are required to demonstrate the ability to differentiate normal from pathological health assessment findings (Table 3). To accomplish this task, the students use their selected nursing model to elicit a comprehensive health history and physical assessment. Findings that are a normal agerelated change are highlighted in yellow on their paper; those that are abnormal and suggest pathology are highlighted in blue.

Students learn that assessing an older person can be very different from obtaining an assessment on a younger person. One student commented "It took me several hours just to get the history. I went back twice because I was afraid I'd wear her out. Then it hit me - she's 96 years old - no wonder it's taking so long. She's had a long life."

As part of the comprehensive assessment, the students also assess the client's mental status and morale. Assessment tools used include the Short Portable Mental Status Questionnaire (SPMSQ) and the Runter Morale Scale.

Table

TABLE 4OPTIONAL CLINICAL ACTIVITIES

TABLE 4

OPTIONAL CLINICAL ACTIVITIES

Graduate students vary widely in their abilities to conduct a comprehensive assessment and to recognize agerelated changes. This activity can be repeated in whole or in part by students who need to improve their assessment skills.

Another aspect of assessment required of the students is performing a functional assessment. Many of the students have never conducted a functional assessment. Students are provided with several different functional assessment tools. For example, Lawton's Physical Self-Maintenance Scale, and the Residential Functional Assessment Scale of the Jewish Center for the Aged are reviewed. Once students obtain the data for the functional assessment, the data are analyzed. Students discuss how their nursing practice decisions were influenced by the findings (Table 3).

My client, although quite frail at age 86, scored well on the functional assessment tool. My goals are to initiate measures to sustain her functional abilities. I have encouraged her daughter to allow her to do as much for herself as she can. We've discussed adding handrails in the shower area to make bathing easier and safer. Because Mrs G's daughter tends to be overprotective, we've discussed the importance of allowing Mrs G to continue to participate in household duties.

My client suffered a stroke and was left with left-sided weakness, lhe physical self-maintenance scale reveals that Mr C has limited functional abilities but can feed, dress, ambulate, and bathe himself with assistance. According to the SPMSQ, his intellectual functioning is intact. Therefore, Mr C will be actively encouraged to participate in all selfcare activities, including eating his meals in the dining room of the nursing home. His clothes will be assessed to determine if they can be easily put on and removed despite his left-sided weakness.

Because the home environment is a crucial factor in determining functional independence, students also learn to conduct home assessments (Table 3). Each student is provided a home assessment form, which includes questions concerning the physical environment (ie, location and proximity to other homes, public transportation, shopping areas, recreational facilities, healthcare facilities, and churches). Students assess the general condition of the clients' home and household contents. Adequacy of the home structure (doors, stairs, hand railings, door knobs, locks, and flooring) are assessed for safety and impingements to independence. Because of such an assessment, one of the students and her preceptor discovered that a client scheduled for discharge would be unable to fit his wheelchair through the bathroom door. Thus, modifications had to be made in the care plan to ensure the client was able to toilet himself.

Once the adequacy and safety of the home is ascertained, the students analyze the data, develop nursing diagnoses, and, when appropriate, suggest community resources. Resources that have been suggested for clients include transportation and nutritional services from the Area Council on Aging or local churches, referrals to community senior centers for socialization, referrals to community volunteer organizations for minor home repairs, and referrals to the Medicaid Waiver Program for housekeeping services. Unfortunately, there are often waiting lists for these types of services; however, the clients appreciate the students trying to assist them and providing them with the information.

The final required clinical practicum assignment is for the students to select an institutional assessment tool and perform an assessment of a long-term care facility (Table 3). Students review a number of institutional assessment tools and conduct an assessment. This activity provides students with an opportunity to critically evaluate how well an institution is meeting the needs of its older clients. Most of the assessments are conducted in nursing homes, and the students are often impressed by the efforts the institutions are initiating to provide care for the residents. This finding surprises many of the students and challenges their stereotypical views of the nursing home.

Students share their institutional assessment findings and conclusions with their preceptors so that the facility has the benefit of feedback. The institutional assessments have in some cases revealed areas needing improvements. The students have been able to plan teaching or change projects directed at helping the institution remove identified deficiencies. For example, one facility was having trouble with the residents finding their way back to their rooms. Two of the students devised a system of placing different colored floral bows on the room doors in the nursing home. This system helped the residents identify and return to their own rooms.

The optional clinical activities provide students with the opportunity to pursue an interest or an area for farther development. Students who choose to develop a job description elaborate on the five roles for the specialist in gerontological nursing: clinician, teacher, researcher, consultant, and administrator. Students emphasize the roles differently depending on their particular interest. The students compare their job description with an actual job description for a nurse at the practicum site. This activity assists the students to conceptualize the role. However, the students often see the inadequacies in the actual job descriptions and try to compensate for those in their papers. Plus, their job descriptions are generally very thorough, but somewhat overzealous. Eiculty guidance is necessary to assist the students to develop realistic expectations for the specialist in gerontological nursing (Table 4).

An eye-opening experience for the students is to explore the age demographics of their own communities and the available resources for long-term care. Statistics published by the state are used by the students to determine the numbers of older persons and percentage of the population over the age of 65 in their county. Information on income and poverty is also ascertained. Available resources are identified by looking in the phone directory under appropriate headings, reviewing materials published by the Area Council on Aging, and by questioning their preceptors (Table 4).

The students residing in the same area often work together to complete this assignment. Once the assessment is made, the students project the need for additional resources. Consistently, the students have projected an additional need for both community and institutional resources to meet the future needs of older persons in their area. Often, they have found a current need for resources to assist older persons in their community.

Related to the activity just discussed, some students elect to explore in greater depth the available services for long-term care in their communities (Table 4). To complete this activity, the students may work in groups to develop a directory of services. Agencies that offer long-term care services are contacted. Students explore with agency representatives the types of services offered, eligibility requirements, funding for services, cost of care, use of the service, and need for additional services. The directory of services is then a valuable resource for the students to use with their clients.

Students also have the option of developing and conducting teaching projects with the nursing staff or a group of clients. The students have instituted a variety of programs, including conducting classes on safety and life management for participants at senior centers, teaching nursing home staff how to assess nasogastric tube placement and tube feed patients, and one student had a major role in helping develop the educational materials for nursing home aides that prepared them for state certification. The teaching plans and the actual teaching process are evaluated by the students and discussed in their journals (Table 4).

Change projects are developed and implemented by some of the students. The preceptor often identifies a problem area at the practicum site and is then most appreciative of the students' efforts to develop a strategy and plan to alleviate the problem. The change projects are written and the plan is substantiated by change theory. Students typically use Lewin's change model of unfreezing, moving, and freezing or Lippit's seven-stage model to organize their plans (Table 4).

Several different change projects have been initiated by the students. One student identified that the assessment format and process at the nursing home was cumbersome. The student and preceptor agreed that a new approach was indicated. The student worked to develop a check-list type of assessment format and worked with the preceptor to develop a policy for conducting the assessments. The change project then addressed the procedures to be followed with the staff to ensure the new assessment policy and procedure would be accepted. Other change projects have resulted in the initiation of bowel and bladder training programs and reminiscence therapy classes for nursing home residents.

A final optional activity is related to the researcher role of the nursing specialist (Table 4). Students have identified a variety of researchable nursing problems. The problems are drawn directly from their clinical experiences with older adults and are substantiated by a literature review. Some students have developed their ideas further as a basis for a thesis. FOT example, one student studied restraint use in confused hospitalized persons over the age of 65.

CONCLUSION

Student evaluations of the course have been positive. They tend to dislike the amount of writing required, but report that writing helps them to analyze the experience. Many of the students describe having a different (positive) attitude about working with older persons after taking the course. One student wrote in her journal: "I had an exciting day. An oldster told me she loved me. And I said *I love you too.' I've decided I love working with old people at the nursing home. I thank you for the opportunity to learn this about myself this quarter."

As for program graduates, several students who are now employed by schools of nursing state that they are the faculty advocates for gerontologicai nursing. Two other students applied for and were hired in administrative positions at Veterans Affairs hospital nursing homes. Three other graduates work for the State Department of Health in the division that reviews and licenses nursing homes.

Overall, until a change is seen in job opportunities and appropriate compensation for master's prepared gerontological nurses, the numbers recruited into the field will remain small. This is unfortunate because master's prepared nurse specialists, as well as other nurses interested in gerontological nursing, are in a position to improve the quality of care for older persons. The well-prepared nurse, with the use of specialized knowledge and clinical experience in gerontological nursing, can influence not only individual client care, but also the decisions of policy makers.

REFERENCES

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TABLE 1

COURSE TOPICAL OUTLINE

TABLE 2

REVIEW OF RESEARCH ACTIVITY

TABLE 3

REQUIRED CLINICAL ACTIVITIES

TABLE 4

OPTIONAL CLINICAL ACTIVITIES

10.3928/0098-9134-19910401-07

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