The letter read: "I saw the advertisement for your gerontological workshop series to be presented in Great Falls in November January, and February. I will not be there, and I want to tell you why. I live in the northeast corner of Montana and, though you claim Great falls is centrally located, it means I would have to travel over 400 miles (one way) to get there, possibly in a snowstorm given the months you have chosen. It would take me one day each way to drive, not to mention the price of gas, plus a motel bill for three nights and the registration iee (though $100 for three 2-day workshops is pretty reasonable!). Besides that, my disabled elderly mother lives with us, and I prefer not to leave my teenagers unsupervised for nearly a week. My nursing home administrator tells me I will not be paid for the days I am gone, and can't get anyone to cover for me anyway. I hope you are planning to offer the workshops again, possibly in Sidney, which is only 100 miles away."
DISTANCES OF RURAL COMMUNITIES FROM MAJOR CITIES IN MONTANA
This letter (based on actual correspondence) represents a composite of the types of problems that are faced by many nurses in Montana who would like to take advantage of gerontologicai continuing education programs. Conversely, for a gerontological expert to go to Sidney, as requested, would mean a similar story for the traveling instructor.
As can be seen from this illustration, it is a real challenge to provide quality gerontological continuing education to practicing nurses who care for the elderly in rural settings. Responding to this challenge, the Nursing Approaches to Quality Care for the Elderly project developed a series of 10 serf-study gerontological nursing modules, which put a wealth of current gerontic information at the fingertips of geographically isolated nurses in Montana.
Nursing Approaches to Quality Care for the Elderly was a continuing education project with the ultimate goal of improving the quality of nursing care received by Montana's elderly by enhancing the gerontological knowledge of nursing teams (RNs, LPNs, and nurse's aides). Funded by the Administration on Aging and jointly administered by Montana State University's College of Nursing, Office of Extended Studies, and Center of Gerontology, its objectives were to:
* Define and level gerontological nursing content for each of 10 programs;
* Deliver workshops at five sites in Montana;
* Develop strategies for disseminating program content to nursing personnel unable to attend on-site workshops (self-study modules);
* Establish a financially independent program; and
* Increase the number of registered nurses who could successfully pass the American Nurses' Association (ANA) certification examination for gerontological nurses or gain continuing education credits.
Gioiella reminds us that "nurses are the principal providers of geriatric care, not just because of our numbers, but also because we offer the kind of care elderly people need."1 Carnevali and Patrick, however, admonish us to be aware that "nursing has a long way to go in terms of achieving adequate recognition of its contribution."2 This awareness needs to be nurtured among nurses themselves as well as in the general population of consumers of nursing's services. For this reason, one of the overall guiding principles used in developing the project programs was the emphasis on nursing approaches to maintaining the health and combating the health problems of elders.
If nursing is to deliver on its promise and potential, the ANA says that nurses who care for the elderly need to be prepared to assess the health and functional status of older adults, plan and provide appropriate nursing services, and evaluate the effectiveness of such care.3 Implied in this statement is a strong commitment to promote health with well elders and educate those with chronic illness to live quality lives despite the limitations the illness may impose. This, then, becomes a framework within which quality nursing care for the elderly can be provided and was the structure chosen within which to present the content of each of the 10 programs.
However, many nurses who are responsible for caring for elderly clients have not been prepared in gerontology and geriatrics. Two reasons are that gerontics is a relatively new field and mat its content has not been included in the curricula of nursing schools until recently. Therefore, in the opinion of Russell, the deficiencies that exist in the preparation for gerontological nursing will need to be remedied through continuing education programs long after nursing schools have learned to adequately prepare nurses in the care of the elderly.4 The situation in Montana was no exception. A continuing education program that focused on nursing care of the elderly, including assessment, planning, treatment, health promotion, and evaluation of care, needed to be developed to provide quality nursing care to the state's aged citizens.
An even greater challenge was providing quality gerontological continuing education to practicing nurses who care for the elderly hi rural settings, which characterizes most of Montana. Nurses who practice Ui isolated areas and very small communities are not exempt from contact with elders and are eager to deliver quality care to this segment of their case load, whether it is in hospitals, nursing homes, home care, or residential settings. Data to support these statements are found in Montana's demographics and the results of a 1986 assessment of the continuing education needs of a sample of nursing care providers who serve Montana's elderly.
Montana's Demographics and Other Statistics
The problems of preparation and availability of nurses to care for the state's elderly are compounded by the fact that Montana is a large rural state with widely varying topography, unpredictable weather, and limited transportation systems. Montana ranks 4th among the 50 states in terms of size and 44th in population; the overall population density is approximately 5.4 per square mile as compared with 64.0 for the United States, and there are only 14 towns in Montana with populations over 5,000.
The demographics of Montana's elderly are similar to the national average in terms of proportion to the population but not hi distribution; ie, 1 19,240 persons 60 years of age or older reside in 56 counties distributed over an area of 147,138 square miles. The distribution of the aging population throughout the vast expanse of the state means that many health-care providers work in sparsely settled areas. For most, access to continuing education is compromised by their relative isolation from major educational centers. While there are insufficient resources to send instructors to a large number of distantly scattered sites to provide the education, conversely, it is difficult for healthcare agencies to free-up employees to attend extended educational programs at distant educational centers.5
Transportation is time consuming and is often influenced by weather. For example, to present the 43 workshops that were associated with the project, the principal investigator traveled nearly 13,000 miles in a little more than 2 years driving within the state of Montana, not to mention the miles traveled by the participants (approximately 130,000). To illustrate the distances involved, the rural communities that participated in the needs assessment are shown in relation to their distance from the major cities of the state (Table). As can be seen, distances are great and only one of these communities is within 100 miles of a major city.
The potential influence of winter weather on access to continuing education is demonstrated through the experiences of the principal investigator, who was snowed in three times and had to reschedule two workshops during the project's activities, despite the fact that the months of December and January were deliberately avoided. Our experience in offering continuing education programs in Montana and results from the needs assessment showed that there are only five months that can be used productively for continuing education sessions. More than half the year is lost if workshops are solely depended upon for delivery of information to Montana's nurses. Although our data are limited, it is not unreasonable to suspect that continuing education deb' very constraints related to weather problems do exist in other northern rural states and perhaps in the summer in desert states.
REPRESENTATIVE TABLE OF CONTENTS
In the spring of 1986, a continuing education needs assessment was developed using the Guidelines for Conducting Training Needs Assessments developed by the Center for Public Management for the Administration on Aging in 1980. The sample included 144 nursing team care providers (53 RNs, 32 LPNs, 59 nurse's aides) involved in the care of the elderly. They lived in four widely dispersed rural communities of Montana, which represent the characteristics typical of many Montana communities: they are isolated from population centers and small in population (2,661 to 7,104 people X and one town has a population of 21,645. In addition, the health-care providers were interviewed in a town with a population of 620, representative of the size of 324 Montana communities of fewer than 1,000 people, regarding rural continuing education needs.
The results of the needs assessment were useful in planning the focus and content for the workshops and modules. For example, because 48% of the registered nurses had worked in gerontological settings for more than 10 years, many had never been exposed to the concept of "nursing process," which was introduced in the mid1970s. This finding reinforced the decision to use the nursing process as the organizing focus for the programs and to reiterate in every workshop and module its relationship to the standards of gerontological nursing care. The nursing problems selected to be addressed in the program series were those identified in the needs assessment as areas about which information was most frequently requested.
How, then, to provide quality gerontological continuing education to practicing nurses who care for the elderly in rural Montana? The challenge was at least two-fold: accessing the often place-bound practicing nurse while doing it cost effectively. It was postulated that one way to accomplish these ends would be a combination of presenting strategically located workshops using videotaped experts, and further using the videotaped experts by developing self-study modules based on the workshop sessions.
Consequently, the workshops and self-study modules developed by the Nursing Approaches to Quality Care for the Elderly project either allowed the nurse to come to a program closer to home, reducing travel distance and time away from the workplace, or provided an opportunity for the nurse to study at home, eliminating costly and hazardous travel and the need to leave the patient's bedside.
Each of the 10 programs was to be prepared for delivery in three modes: live sessions headlining prominent guest presenters for the initial program presentation; extended site workshops in four Montana cities featuring the videotaped experts from the live sessions and a program facilitator with expertise in gerontological nursing; and self-study modules to make the programs accessible to any group or individual unable to attend the workshops.
Nationally and regionally known experts were recruited using the assistance and resources of the Geriatric Education Centers of the Universities of Washington and Utah, University of Arizona, and Montana State University (MSU).
Gerontological Nursing Content Defined
Based on the needs assessment and judgment of gerontological nursing experts, the topics chosen were introduction to nursing care of the elderly with an emphasis on the ANA Standards of Gerontological Nursing Practice, the normal aging process and its implications for nursing, and in-depth nursing approaches for eight nursing diagnoses that are commonly seen in the elderly (problems with mobility, sensory/ perceptual deficits, thought processes, home maintenance management, nutrition, skin, elimination, and hypoxia). Program content was organized within the framework of the ANA Standards of Gerontological Nursing Practice (nursing process) and emphasized patient education and health promotion. The Figure lists a representative table of contents,
Gerontological Nursing Content Leveled
A unique feature of the programs was the attempt to designate content for one or more levels of the nursing team, ie, registered nurses, licensed practical (vocational) nurses, or nurse's aides. The bases for these decisions were the Montana Nurse Practice Act definitions of nursing practice for registered nurses and licensed practical nurses. Although nurse's aides are not licensed (but are currently being certified) and, therefore, are not defined in the Nurse Practice Act, they are responsible for reporting observations and carrying out delegated basic hygienic and nursing care measures. Using these descriptions as general guidelines, the programs were organized to reflect the varying responsibilities of the nursing care team members. Although none of the information in the programs was restricted to any particular member of the nursing care team, it was considered important that each member of the care team be aware of specific roles as defined by the Nurse Practice Act and that the information be used appropriately within that role.
Ten workshop series were presented at five sites in Montana. Although this represented a potential of 50 workshops, 43 were actually presented; 7 were canceled because of insufficient enrollment. The initial workshop for a program was presented "live" by a nationally or regionally known topic expert in Bozeman, the location of MSU. The content from the live session was videotaped on the following day in a "conversation with the expert" format. These videotapes became the core of the workshop, which was replicated at four other sites in Montana: Billings, Great Falls, Miles City, and Missoula. The conversational nature of the videotapes and frequent breaks with question and answer periods moderated by a "live" gerontological nurse practitioner resulted in a high level of acceptance of the videotaped segments by the workshop participants.
Program Content Disseminated Via Self-Study Modules
The strategy used for disseminating program content to nursing personnel unable to attend on-site workshops was the development of 10 self-study modules, each equivalent to one 8-contacthour session. Each program was converted to a self-study module that included the videotaped interviews and demonstrations, a 100-page booklet, and other learning materials used in the workshops. These modules are available for either purchase or rental through the MSU Office of Continuing Education for the Health Professional.
Working Toward a Financially Independent Program
To establish a financially independent program and maintain the availability of the modules after the grant funding expired required fees to be charged for workshops and for rental or purchase of the self-study modules. Income from extended site workshops did not cover the cost of presenting the workshops, even if the cost of videotape production was not included. Attendance at all the workshops totaled 634 and ranged between 4 and 28 per session with a mean attendance of 15 - a figure that was not sufficient to support the cost of advertising and presenting the workshops. This information prompted the decision to limit future workshops to those requiring hands-on activities and to rely on self-study modules for the major portion of gerontic information transmission.
Limited experience has been gained in the marketing and distribution of the modules. However, it is anticipated that the self-study module will prove to be the delivery method of choice for continuing gerontological education for the nursing teams of Montana and other rural states, provided the fees can be reduced to the point where they will attract individual nurses. Group rentals are currently the most economical method for obtaining the modules, and are gaining popularity in Montana and Colorado. Larger agencies in Maine, Washington, Utah, Alaska, and Canada have purchased the modules outright.
Nurses Informed of ANA Certification Process
At this time, data are not available regarding the numbers of registered nurses who successfully passed the ANA certification examination for gerontological nurses as a result of attending the workshops or completing the modules. Perhaps the greatest contribution made by the project was to inform nurses that certification is available to them. Sixty-four registered nurses, many of whom did not previously know about the ANA certification program, indicated an interest in eventually becoming certified as gerontological nurses.
Continuing Education Credits Earned
All programs were approved for continuing education credits by appropriate nursing groups. A total of 357.55 CEUs (equivalent to 3,575.5 contact hours) and 674.5 contact hours (without CEUs) were earned by nursing team members during the project - a total of 4,250 contact hours of continuing education for Montana's nursing caregivers in gerontological settings.
IMPLICATIONS AND SPINOFFS
This project is seen as the first phase of a broader attempt to bring continuing education opportunities in gerontological nursing to nurses in rural areas. Future plans include the production of 10 additional modules; wider distribution of the modules nationally and internationally; integration of the modules into undergraduate and graduate nursing curricula, including university credit home study options; consideration of technological strategies for transmission of the modules via television or computer networks; and other creative applications for module use.
Phase II, which has been approved and funded as a special project through the Division of Nursing, will make possible the development of 10 more modules: Issues and Trends that Impact the Giving of Nursing Care to the Elderly, Pharmacological Nursing Care of Elders, Educating Health Care Personnel to Provide Quality Care to the Aged, Supervision and Management of Health Care Personnel, Communication Skills, and Nursing the Elderly in Acute Care Settings. Four additional nursing diagnoses common in the elderly will be targeted for development in the final modules to complete the series. The original 10 modules (gerontological nursing standards, normal aging, and eight common nursing diagnoses in the elderly) will be revised and updated. Taken together, the 20 modules will address all the topics covered in the ANA certification test for gerontological nurse.
Active marketing of the modules through the MSU Office of Continuing Education for the Health Professional will be expanded to 14 other Western states initially. Based on the response to the initial marketing effort, national and international distribution may be attempted.
Use of the modules in the nursing curricula is currently being planned at MSU College of Nursing as it prepares to teach a new course, Nursing Care of Aging Adults, on three distant campuses throughout the state. A logical extension of this work would be the development of one or more home study courses for university credit that could fulfill part of the gerontology requirement in the undergraduate and graduate curricula. This opportunity would be well received by nurses in outlying areas who wish to earn a BSN or MSN.
Consideration will be given to new technological strategies. One idea is to design broadcast quality videotapes that will be compatible with television broadcast schedules, should this mode of module transmission become feasible through the auspices of the public television station housed on the university campus. Thought has been given to extracting short abstracts from the modules and converting them to halfhour to 1-hour computer assisted instruction programs that can be accessed through a computer network and to which continuing education credit could be assigned. Ways in which nurses in rural areas could problem-solve by telephone networking with gerontological nursing experts and one another or the use of interactive audiotapes within the module structure could be explored.
The modules are rich resources that lend themselves to many applications. For instance, cooperative ventures between several regional nursing homes have resulted in a consortium approach to using and sharing the modules between agencies, resulting in savings of time and money. Appropriately selected segments from the modules have already been used in 15 workshops statewide to provide continuing education programs for more than 400 inhome caregivers through the sponsorship of Montana's Area Agencies on Aging. In addition, 10 model community health promotion programs designed to be presented to communityliving elders (a feature of each of the workshops/modules) have been compiled and bound into a single document that focuses on health promotion.
State and regional networking, coordination, and cooperation between professional groups in the West maximized the use of gerontological resources within the project and forged cooperative relationships. It was an orchestration that contributed to the success of the project and is expected to enhance the second phase, Gerontic Continuing Education for Rural Nurses Who Serve the Aged.
And so, to our letter writer from Northeastern Montana who poignantly described the problems of accessing quality gerontic continuing education programs in rural areas, we can say the challenge has been accepted. In response to pleas, self-study modules have been developed and other strategies are being examined that allow nurses to economically access gerontological nursing content without leaving family and workplace or risking long-distance travel in questionable weather.
- 1. Gioiella EC. The right choice for geriatric care. Nursing and Health Care. 1987; 8(8):439.
- 2. Carnevali D, Patrick M. Nursing Management for the Elderly. Philadelphia: JB Uppincott Co; 1979:11.
- 3. American Nurses' Association. Standards and Scope cf Gerontological Nursing Practice. Kansas City, Mo: Author; 1987:23.
- 4. National Technical Information Service, US Department of Commerce. Geriatric Educational Program for Nurses. Springfield, Va: Author, 1983:9.
- 5. Progress Report and Future Plans cf Area Health Education Development Project at Montana State University. Unpublished manuscript. 1986:7-8.
DISTANCES OF RURAL COMMUNITIES FROM MAJOR CITIES IN MONTANA
REPRESENTATIVE TABLE OF CONTENTS