Controversy continues regarding the inclusion of gerontological content within nursing curricula. Some authors argue for separate courses, some feel the integration approach best prepares the student, and others feel gerontological nursing belongs only as a graduate specialty.1·5 Edel found undergraduate nursing programs lacking not only in gerontology-related content, but also in faculty prepared to teach this agespecific information.6 Negative attitudes held by the faculty may actually impede the integration of gerontological nursing content into the curriculum.7
In 1975, the American Nurses' Association (ANA) began to advocate for the inclusion of gerontological nursing in the undergraduate curriculum: "basic and graduate education programs for registered nurses need to emphasize gerontology and geriatric care, not only in the classroom but also in clinical facilities."8 A report by the House Committee on Appropriations stated that "national public policy has set a course directed toward 'action to improve and expand training hi geriatrics and gerontology* in the health professions."9 Recently, the need was emphasized again as part of the recommendations stated in the final report of the Commission on Nursing of the US Department of Health and Human Services.10
Georgetown University School of Nursing, Washington, DC, responded to this documented need by developing a 4-year integrated continuing care approach to incorporating gerontological nursing into the undergraduate curriculum.
Realizing that planning a 4-year integrated approach would require a unique blend of the "right" clinical settings plus capable faculty prepared in gerontology, the project faculty was carefully chosen. A variety of clinical agencies were represented with each member being appointed to adjunct faculty status. Agency faculty members included representation from an adult day care center, visiting nurse agencies, nursing homes, a rehabilitation hospital, and the in-hospital geriatric medical specialty care unit at Georgetown University Hospital.
Clinical agencies must be convinced of the value of students having experiences that are broader than the traditional community experiences and that involve service agencies whose focus is clients and not necessarily student learning. Although the undergraduate nursing faculty remained very small, the School of Nursing was unique in that two of the full-time faculty members had past preparation and expertise in gerontological nursing. Additionally, these two faculty members were in the positions of course coordinators for two key courses in the undergraduate curriculum: the medical-surgical nursing and the community health nursing courses. Because the School of Nursing also offers graduate level courses in gerontological nursing, two graduate level faculty members shared their knowledge as the curriculum plan was being developed.
Although the faculty of the School of Nursing was dedicated to developing a 4-year integrated approach to the teaching of gerontological nursing within an undergraduate program, they were not willing to undergo a major curriculum revision. The present curriculum, based on the Self-Care Deficit theory, was carefully analyzed using a modification of a tool designed to assess content areas within a graduate level gerontological nursing program.1
Based on a careful review of course outlines and student handouts, as well as discussions with course faculty, the project faculty found that the present curriculum contained traces of all the essential content needing to be included.6 The project faculty recognized that although the content may be included, it needed to be strengthened and possibly expanded. Additionally, clinical experiences needed to be carefully planned to promote a positive image of the elderly. Because America's older population is drastically increasing, the number of older adults in all settings within our society is also increasing. Although the project faculty realized that not all of the School of Nursing's graduates would choose to enter the field of gerontological nursing, they were committed to assisting undergraduate students in considering the elderly as valuable members of America's society.
Therefore, the challenge was to find the best methods of preparing nursing students to understand and address the needs of the elderly population. Nursing knowledge and skills must be employed to care not only for the acutely ill, but also to promote health and to provide health maintenance and rehabilitation. To do this, the educational experiences must include both acute and community care. That was a basic assumption. But how could this best be done within the tightly scheduled baccalaureate curriculum, where the focus has often been primarily on acute hospital high-technology care, not necessarily with a strong focus on the aging person? The use of the continuum of care services proved to be the answer; but the value of these types of clinical experiences must be convincingly demonstrated not only to the students but also to the faculty.
THE 4-YEAR INTEGRATED APPROACH
In most BSN programs, students are not admitted to the nursing major until the second semester of the sophomore year. However, at Georgetown University School of Nursing, students are admitted to the nursing major as freshmen. To integrate freshmen into the nursing school, a freshman nursing course was begun in the 1987-1988 academic year, which was the year prior to the start of the funded project. This course provided freshmen nursing students with an overview of nursing and began their socialization to nursing as a profession.
In this freshman nursing course, because of the diversity of nursing specialties, speakers were invited to share what it means to be a nurse within their particular setting. By using the ANA gerontological nursing practice standards as a focus, the role of the geriatric nurse was expanded. The presenter provided examples showing how the roles of the gerontological nurse were implemented and then proceeded to expand on the personal satisfaction received in interacting with older adults in a variety of settings.
A human growth and development course during the students' second year included 8 hours of content related to the older adult. Students initially received an "Aging IQ" quiz, which stimulated discussion regarding some of the common myths and stereotypical attitudes toward the elderly.11 Additional content included normal physical and cognitive changes, developmental and aging theories, demographics, lifestyle changes including alternate living arrangements, and an overview of ethical, legal, and medical issues.
As part of the sophomore level nursing theory courses, the clinical portions included a planned series of interactions with the elderly. Gerontologically focused content and readings were integrated into these courses. A gerontological text was incorporated into the sophomore, junior, and senior years. A total of three clinical experiences were planned with the residents of the US Soldiers* and Airmen's Home (USSAH) in Washington, DC. Two of the planned clinical experiences occurred on grounds of the USSAH, and the final encounter was a planned interaction and reception on the university campus.
Prior to the experience, the faculty discussed the purpose of this particular learning opportunity. Three objectives were identified and explained to the students: initiate, maintain, and terminate a relationship with an elderly client; identify Ufe cycle events that influence the client's selection and maintenance of self-care practices; and describe one's own cultural and ethnic orientations as nurse agency with respect to the clinical and ethnic orientations of the client.
Several of the students were apprehensive as the first day of this clinical experience approached. Certain attributes of the elderly often elicit a negative response, and the students voiced concern regarding the possible physical disabilities of the population, their cognitive limitations, and questioned appropriate topics of communication besides illness, death, and dying.12 Once the students actually arrived at USSAH, their apprehensions soon subsided.
Many of the veterans proudly wore their medals and were quick to share stories of their military lives. The students were frequently astounded by the acts of heroism these men had performed during the wars. Many of these elderly men had once been leaders of troops, organized battle plans, and directed the Uves of the men under them. Several of the men shared stories of traveling to foreign countries and meeting great leaders.
Although the number of women at the USSAH is small (4.9% of the total population) two women volunteered to be part of mis clinical group. They, too, shared their military experiences and travels with the students. One of the women made it very clear that although she had a "bad knee," it did not keep her from being active and traveling, even now.
One student found it interesting that her member enjoys some of the same types of music that she enjoys. On her second visit to the USSAH, the two of them sat and listened to music from a compact disc player. At the end of the day, the member gave the student two tapes of music he recorded for her. The student was amazed that the tunes were "top 40" rather than "oldies but goodies." This student stated that the clinical experience provided her with additional insight into the feelings of being an older adult. Until now, she had not really thought of the elderly as being people with feelings just like her, even enjoying some of the same pleasures in life.
The junior year gerontology experience was unique. Georgetown University Hospital is one of the few institutions with a recognized geriatric medical specialty care unit. This 19-bed unit provided the opportunity for students to work with the older population in a specialized in-hospital setting. Many of the nurses on this unit were young, and several had advanced education in the area of gerontological nursing. All of the nurses on the unit had requested to work there and felt a great sense of pride in the care they gave this unique population.
It was easy to plan a holistic experience related to the unit's unique population for junior students during a 3week rotation. Specific criteria stipulated that only persons with potential rehabilitative abilities were admitted to this unit, and the staff had become strong patient advocates for this elderly population. The unit conveyed a warm and caring attitude and actively promoted a positive attitude toward the older adult.
Each student was assigned an individual patient to interact with for the entire rotation. Because of the age of this population, these patients were often hospitalized for an extended time. Patients were chosen carefully to provide the student the opportunity to not only gain experience in technologies, but also in communication skills with the older adult. The student assignment involved completing a case study centered on the particular older adult with whom the student had been interacting.
There were several aspects to the case study format The student initially completed a physical assessment on the patient, but this was only the beginning. Building on the theories of aging and the exposure to growth and development theorists that the students received during their sophomore year; the students were required to apply these theories to then· particular clinical experience. Students also gathered information about the past life experiences of this older adult. This information was collected in a variety of ways. In addition to talking to the patient, previous medical records were available; family members, guardians, or other caregivers also enjoyed sharing information with the students, as did the staff nurses on the unit. The staff nurses were excellent resources for the student and openly shared information with them.
Detailed nursing care plans were also expected from each student. Using the Self-Care Deficit theory as a framework, the student developed four selfcare deficits from the universal selfcare requisite through the evaluation of care. The self-care deficits equally addressed both the physical and psychosocial needs of each individual older person. As the care plans were developed, appropriate community services were also identified. At one point, the students prepared a community resource directory for senior citizens and presented it to the unit staff. Students also participated in interdisciplinary rounds and shared ideas with other health-care professionals.
Planned postconferences were an important part of this clinical experience. Students were assigned to lead discussions on various medical, ethical, and legal issues related to the care of the elderly patient. Topics included euthanasia, living wills, medication misuse in the elderly, rationing health care, and legal guardianships. Students supplemented faculty-supplied information with data related to their particular patients, family and personal experiences, newspaper articles, and information from various journals.
Students' responses to this experience have been positive. For many of these students, this experience counteracted preconceived myths and stereotyped views regarding the elderly. Few of the students became convinced that they would now become gerontologicai nurses, but almost all of the students stated that they had changed their views toward the elderly. The students indicated that they received a great deal of satisfaction in caring for the elderly because they felt that what they did made a difference in that person's life. Several responded that these people appreciated ¿he care and that they felt satisfied. These students began to see these older adults more as people who happen to be older, rather than as a part of that "aging population" about which society keeps talking.
In the senior year, the students have two clinical courses: nursing in the community and complex problems in nursing. The community health course provided a natural opportunity to continue the gerontological experience. Some students carried clients in a certified home health-care agency; others participated with the elderly at an adult day care program and also worked with the nurse case manager at a community senior center. Other students had their experience at a retirement community. The community senior center has a volunteer home visitation program after acute hospitalizaron. This center also provided the opportunity for the interdisciplinary interaction that is necessary in community-based care, with the nurse as case manager. The retirement community has a long-term care facility on its campus, two discharge planning nurses who link with two acute care hospitals, and community health nurses for follow-up care either in the clinic or home. The student clinical experiences have been building toward the community health experience in which the students function independently in community-based settings and the home environment. These clinical sites allowed the students to work with the elderly along a continuum of care.
As the population ages, the number of elderly clients covered by home health agencies has also increased. Most of these clients are post-acute care; these are the clients to whom the students in the different clinical settings were exposed. In addition, some of the students were in settings where ongoing care was an integral part of the program, not only the post-acute care services that were considered "skilled" and therefore reimbursable under Medicare. However, in all settings, the students were aware of the implications of reimbursement for the care that was provided.
An experience with continuing care coordinators in the acute care hospital was built into two clinical sites. For students who were still learning how acute and community care fit together; the experience with the continuing care coordinator was pivotal. In planning for ongoing care with the gerontological patient and family or significant other, the student practiced shared decision making and learned what community resources were available. This piece of the community health experience with the discharge planner or continuing care coordinators highlighted the following considerations:
* An elderly hospitalized patient may be independent in serf-care at discharge and not need follow-up care in the community.
* An elderly hospitalized patient may require a referral to a certified home health agency for intermittent skilled nursing care or rehabilitation and the assistance of a home health aide in the home.
* An elderly person may live with family or others who work, and a referral to an adult day care center for stimulation and supervision during the day may be made.
* An elderly patient may be transferred after hospitalization to a skilled nursing facility for continuing care. This may be especially true for intensive rehabilitation with the long range plan for discharge to home after rehabilitation. It is important for students to be aware that the nursing home need not be a permanent placement; in the past, nursing home placement has often meant the "last stop."
* An elderly patient may be discharged to home with a referral to a social service agency for homemaker services or for transportation arrangements.
In the certified home health agencies, the students worked with the primary nurses carrying a limited number of cases/families. Although the students were exposed to high-technology home care, the clients that the students followed were usually less intensive so that the focus could be on the person and family in the home environment, teaching and counseling, interacting with other disciplines (especially social work and rehabilitation therapies), and understanding the community.
The students were able to see the elderly receiving services throughout the continuum of care. The normal physical and cognitive changes, developmental and aging theories, alternative living arrangements, multiple systems pathopbysiology, ethical concerns, reimbursement issues, use of community resources, and an opportunity for limited interdisciplinary collaboration were all a part of this senior experience.
The gerontology project has provided the resources to integrate service and practice. The adjunct faculty from the agencies, who are an integral part of the project staff, supplement the real world dimension of the faculty with an in-depth understanding of each of their agencies or facilities and patients/ clients. The graduates of the nursing program are prepared to function with the older adult having a practical understanding of the fiscal issues that affect service provisions and a broad knowledge base regarding the services that constitute a continuum of care.
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