The following question was asked of the readers of the Journal of Cemntological Nursing:
What types of clinical experiences do you think should be included in geriatric nursing courses at the undergraduate level?
I believe geriatric nursing courses at the undergraduate level should include clinical experiences that expose students to a wide variety of health care and community settings. These may include adult day care centers, church groups, community groups, independent living homes, group homes, and assisted-living centers. Such experiences will provide interactions with many healthy, active, older adults. In addition, experiences in hospitals or other clinical settings would familiarize students with acute and chronic illnesses common to elderly people. Emphasis on health promotion at the undergraduate level would facilitate health promotion activities in ah1 settings in which elderly people are found.
JoNeII Costello, BSEd, BSN, RN, MN
It depends on whether the course is at the sophomore, junior, or senior level, and the framework of the total curriculum. Beginning students should not have clinical experience in nursing homes. Their early experiences should be with well community-dwelling older adults in places such as wellness centers, retirement centers, and senior centers, where students can learn assessment and communication skills. If it is a junior course, home nursing and assisted-living facilities could be considered. Senior-level students in management courses can have excellent experiences in nursing homes. Good role models are important at all of these sites.
Mildred O. Hogstel, PhD, RN, C
Cemntological Nursing Consultant
Fort Worth, Texas
I would like to see public health issues addressed, outpatient clinic issues, more home care, educational instructions toward disease processes, and issues that affect older adults (e.g., living wills, estate planning, Medicare, Medicaid, preventive health).
The issues deal too much with Alzheimer's disease and nursing homes. Many older adults are able to function independently in society.
Judy Michael, RN, BSN
Williamson County Health Department
Public Health & Primary Care
Undergraduate-level clinical experiences should include senior centers, extended care and assisted-living facilities, and rehabilitation interviews with healthy older adults to elicit health concerns, medications taken, activities, their approaches to aging, and so forth.
Sarah Jean Cooper, MN
Walla Walla Community College
Walla Walla, Washington
Students should spend some time in a long-term care facility to learn how to take care of the elderly population. They would learn the principles of good patient care which they could implement in any setting, such as the importance of good skin care, proper positioning, and the importance of good nutrition in the prevention of decubitus ulcers.
Residents in long-term settings have much wisdom they could share with students in a nursing program. Students would learn about residents' rights and how to uphold these rights when they are in positions of authority. Students would learn about restraints and how detrimental it is to restrain residents for staff convenience. They would learn the importance of teamwork in providing quality care to residents in long-term care settings. Teamwork involves all disciplines from housekeeping to the nursing staff.
We need caring professionals in the field of geriatrics, and this love will exist only if students are exposed to the elderly population.
Rose Marie Molinari, RN, BS
Director of Staff Development
Oakland Grove Health Care Center
Woonsocket, Rhode Island
Clinical experiences in undergraduate-level geriatric nursing courses should include experience in long-term care facilities and continuing care communities, and exposure to programs that address health maintenance for elderly people, specifically, programs addressing chronic diseases and functional maintenance.
Karen A. Mueller, RNC
With 70 million "baby boomers" heading toward retirement, it is imperative that as many and as varied clinical experiences as possible be included in geriatric nursing courses at the undergraduate level.
Because interviewing or history taking, vital signs, and glucometer checks are the initial skills learned by first-year nursing students, we offer these services at the local senior citizens' centers as soon as the students are proficient in the laboratory. They learn that elderly people are grateful for the attention and are nonjudgmental of their beginning skills. The students gain self-confidence before the next rotation in the nursing home.
The nursing home experience is divided into two parts. First, there are the basic skills of bathing, dressing changes, and tube insertions (e.g., Foley catheters, feeding tubes, rectal tubes) as the students learn the nursing process of assessment, implementation, and evaluation with written care planning. Second, after students complete the pharmacology course, they should become proficient in distributing medications, with emphasis on the absorption and side effects of drugs in elderly people.
Usually in that first semester, I provide a Skin Workshop with decubitus ulcers made out of flour, so the students can experience probing for wound tunneling and work at removing the black eschar down to healthy tissue. Fruits and vegetables are used to illustrate other types of skin damage (e.g., abrasions, pressure areas, skin tears), which are commonly found in elderly individuals. This hands-on session has proven invaluable to the students, aiding their recognition, assessment, and care of skin problems in the clinical areas whether they are acute care hospitals, rehabilitation centers, nursing homes, or home health.
The rotation at a rehabilitation center and transitional care/subacute/certified distinct part (CDP) of the nursing home focuses on either regaining or maintaining as much of the elderly individuals* functional abilities as possible. This is an excellent opportunity for students to use the Minimum Data Set for assessment, to justify their observations by completing the Resident Assessment Protocols, to participate in care conferences, and to update the care plans with individualized goals. Adult day care is another setting which offers students valuable learning experiences.
Students also can learn leadership skills by being resident advocates for changes in medications, treatment modalities, dietary preferences, and advanced directives. As members of the interdisciplinary team, they learn the nurses' roles in discharge planning from the institution and follow-up care with home health.
Maxine M. McCue, RN, MS
College of Eastern Utah
San Juan Campus
My idea for courses in geriatrics at the undergraduate level is as follows.
10 Perfect Days
Day 1: Classroom time. Overview of physical and mental changes in elderly individuals.
Days 2 to 5: Spend time at a nursing home with the staff indicated below.
Day 2: Spend time with a certified nursing assistant (CNA), the backbone of any institution. Participate with the CNA in performing activities of daily living (e.g., bathing, feeding, dressing, transporting). Helpful hint: Eat a nutritious breakfast and wear comfortable shoes.
Day 3: Spend time with a medication nurse. Participate in giving medication to elderly people with special needs.
Day 4: Spend a day with the charge RN and encounter and solve all problems that arise with residents, families, doctors, all involved departments, and do not forget about admissions, discharges, deaths, and transfers. Helpful hint: Say a little prayer before entering the facility.
Day 5: Spend a day with the Registered Nurse Assessment Coordinator (RNAC). Realize the important job being done (e.g., Minimum Data Set, care planning, interdisciplinary review meetings, reimbursement) - all important.
Day 6: Visit a senior activity center. You will realize that all elderly people are not sick and infirm. The majority are very active people, with much to give to others.
Day 7: Visit a senior day care center. At the center you will learn many things. Keep in mind you may visit for 4 to 8 hours this day. Put yourself in the shoes of a working daughter with a family, who must fill in those other 16 to 20 hours a day for their mother or father. This is quite a task for a member of that "sandwich generation" (i.e., those individuals who are caring for both their children and their aging parents).
Day 8: Attend a meeting of an Alzheimer's disease support group. Listen to the caregivers and the problems faced daily. Having three finals in 1 day does not seem so bad, does it?
Day 9: Visit a geropsychiatric unit. Are you feeling anxious and at one's wit's end some days? Imagine feeling the feelings of some elderly people, and they cannot even begin to think of why or are helpless regarding what to do.
Day 10: Interview an elderly relative or friend. Prepare a repon on your interview and the relative's or friend's views on "getting old" and present it to your classmates. With this project you will find many opinions and views from elderly individuals regarding their "golden years."
Yes, 10 perfect days. Helpful hint: In these 10 perfect days, keep in mind: You have touched lightly only the tip of the iceberg, underneath lies 99.9% to view.
Rose Maldet, RNC
Good Samaritan Nursing Care Center
These clinical experiences should include geriatric emergencies, possibly hospice, do-not-resuscitate orders, and do-not-hospitalize orders.
It is important to know how to respond to emergencies that are common among the geriatric population. Often, I witnessed nursing staff who are so comfortable in the day-to-day routine that when a emergency arises, it often catches them off guard. Hospice also is an important and growing part of the geriatric and long-term care team because when it seems to be an emergency for some clients, it is not.
RoWn D. Siewart, LPN
Philadelphia Geriatric Center
Undergraduate-level geriatric nursing courses should include the following clinical experiences:
* Psychosocial and family assessments.
* Education of residents and families.
* Restraint reduction and fall prevention.
* Care in multiple settings (e.g., senior centers, wellness centers, nursing homes, home health).
* More physical assessments.
* Quality improvement activities.
* Dementia (e.g., behavior modifications, group therapy).
* Functional assessment.
* Incontinence assessment and care.
* Pain assessment and care.
* Advance directives.
As the population ages, nurses will be caring for increased numbers of older clients. Basic nursing curricula need to be updated to include assessment, care, and evaluation of geriatric clients, focusing on the aging process and problems typically encountered in this population.
Mary Anne Bonner, RN1 BSN
Owner and Operator
Nursing Consultation and Inservice
Undergraduate students in geriatric nursing courses should:
* Sit in on an interdisciplinary team meeting about a resident.
* Attend restraint and psychotropic drug education - these are not the answers.
* Attend classes addressing dignity and resident rights.
* Learn how the survey and certification process works and why there are federal regulations for long-term care.
* Learn how the Minimum Data Set assessment process works.
James V. Hohn, Jr., RN
State Department of Health and Human Services
Jefferson City, Montana
Geriatric clinical experiences should include:
* Home care.
* Assisted living.
* Nursing home care.
The field of geriatric nursing is expanding, and those in nursing homes are sicker and more dependent and need nurses with clinical expertise.
Judith L. Roy, BSN, RN
Maine Veterans Home
Gerontological nursing experiences for undergraduate students should focus on acquiring new skills that are appropriate to caring for the majority of elderly individuals who live in the community, rather than on repeating the basic acute care skills learned in other courses. The goal should be to change the students' perceptions that all elderly people are the same (frail, uninteresting, frightening). If an undergraduate students develops an indepth relationship with one elderly individual, the student will gain an emotional, rather than a didactic, understanding of the experience of aging in America.
The purpose of clinical experiences is to learn how older adults adapt to chronic conditions, arrange their environments, manage multiple medications, and use resources and support. Requiring an indepth interview with an elderly individual is a clinical experience that can be used in both gerontological nursing courses or as clinical gerontological content in other nursing courses.
Students should complete Ufe history interviews with elderly individuals whose cultures are different from those of the students. Class discussion of the meaning of culture and aging could precede the choice of interviewees, and aspects of culture that go beyond race and ethnicity could be explored. If time permits, the life histories obtained from the interviews could be shared with the class, to reinforce the idea that the elderly population is interesting and diverse. Two additional written reports should be required of each student: a) a paper that analyzes the elderly individual's medication schedule, including possible interactions, proposals for simplifying the schedule or methods to help the individual comply with a complex regimen; and b) a paper that identifies the elderly individual's most important problem that can be addressed by a nursing intervention and a plan for implementation.
Jill A. Bennett, PhD(c), RN, CNS
University of California, San Francisco
San Diego, California
As a new Director of Nursing in a 60-bed nursing home and having 20 years of acute care nursing experience, along with certification in gerontological nursing, I honestly can say assessment of older adults should be included in geriatric nursing courses at the undergraduate level.
Students must learn the use of simple tools (e.g., Braden scale [Maklebust & Sieggreen, 1996] or the Mini-Mental Status Examination [Folstein, Folstein, & McHugh, 1975], fall risk tools) and what to do when older adults are at high risk, and medications. Students should have clinical experiences in nursing homes and participate in the Minimum Data Set, care planning, and Medicare meetings.
Folstein, M.F., Folstein, S.E., & McHugh, RR. (1975). Mini-Mental State: A practical guide for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
Maklebust, J., & Sieggreen, M. (1996). Pressure ulcers guidelines for prevention and nursing management (2nd ed.). Springhouse, PA: Springhouse.
Trade Nolan Kientz, BSN, RNC
Director of Nursing
The Village Nursing Center
Fork Union, Virginia
I really have enjoyed my rotation in community health. Caring for patients "on their own turf" helps students view older adults holistically and as individuals.
Mary Flanagan Murray, BA
Mountainside Hospital School of Nursing
Montclair, New Jersey
In designing a clinical curriculum for undergraduate students, we envision a four-level curriculum spanning the entire continuum of care from health promotion and prevention to end-of-life care for the geriatric population. Ideally, these experiences could be planned with well elderly individuals in the community setting and advance to administering care to elderly people in nursing homes. Second-level students could be assigned to a hospital to provide care to elderly people with common, chronic complications of aging. At the third level during their mental health rotation, we envision students would be assigned to a geropsychiatric unit to care for elderly individuals experiencing cognitive, sensory, and perceptual complications of aging. Domestic violence and elder abuse issues would be emphasized at this level. At the fourth and final level, we envision students being assigned to a home health care team and a hospice team to experience the expanded role of nurses in caring for the geriatric population.
In the community setting, students would help healthy elderly people do a life review. The process of performing the life review would give the students valuable practice in developing their interviewing skills with older people. The life review would provide a wonderful picture of the developmental tasks throughout the lifespan as they help the elderly people come to terms with the meaning of their lives. In addition to the life review, we ask students to do medication and safety assessments. This brings into focus the variety and interactions of prescribed and over-the-counter medications the elderly individuals are taking. The students must study the elderly individuals* medications and, on another visit, do patient teaching. A safety assessment is performed by the students, at this level, focusing on sensory losses and related safety issues (e.g., burns, falls, lighting, adaptive devices).
The nursing home unit could help students better understand chronic illnesses, rehabilitation, and restorative nursing care. Normal physiological changes seen in people as they age and gerontologie assessment would be important components.
The geropsychiatric unit could provide valuable experiences in trying nonpharmacologic interventions for behavior problems often seen in patients with dementia. The staff would be role models on how best to approach extremely confused older patients. Restraint reduction, fall prevention, and nutritional interventions also would be emphasized. Domestic and elderly abuse issues would be emphasized during this component.
Home health care and hospice care would be the final component of this hypothetical nursing curriculum. We would assist students to administer compassionate care to both terminally ill patients and their families. In this rotation, the students will use all the skills they have learned throughout the program to best help their patients to die with dignity and support them in this process.
Linda O'Keefe-Wood, MS, KNC, CS
Clinical Nurse Specialist
Geropsychiatry SectionBay Pines Veterans
Affairs Medical Center
Bay Pines, Florida, and JoAnn S. Carnahan, MN, RN
Mental Health Strategic Health Croup
Bay Pines Veterans Affairs Medical Center
Bay Pines, Florida and Professor of Nursing
St. Petersburg Junior College
St. Petersburg, Florida
Geriatric educators should consider:
* Hospital-based outpatient and/or walk-in clinics.
* Emergency departments.
* Clinics run by nurse practitioners.
* Community-based senior centers that focus on health promotion, wellness, and education.
* Senior health fairs.
* Home health care experiences.
* Hospital-based geriatric assessment centers or clinics.
* Inpatient or outpatient mental health settings.
* Caregiver and respite care support groups.
* Community-based parish nurses.
* Retirement communities that provide a continuum of care for its residents. These settings should include independent and assisted living, adult day services, dementia care, and skilled and long-term care.
Clinical experiences can only be beneficial and significant to students when accompanied by mentor or preceptors who are eager and willing to share their time, knowledge, and expertise.
As a geriatric practitioner, I invite current and future nurses to share in the challenges and rewards unique to this special profession.
Kathryn M. Schmidtkunz, BSN, RN
Health Care Coordinator/Case Manager
St Camillus Campus
Many people have ideas about what types of clinical experiences should be included in geriatric nursing courses at the undergraduate level. However, in responding to this request for dialogue with peers, one must also remember the following points.
* The things we think should be included should be just that - thoughts, not feelings. When the affective domain has been stimulated with ideas, whole-brained professionals work hard to shape those creative innovations into simultaneously logical recommendations based on scientific principles.
* The purpose of providing input is to stimulate dialogue not debate. Communications through dialogue allows us the opportunity to develop an expanded sense of awareness before we determine whether or not debate is necessary. If substantial conflict is absent or if a premise is scientifically indefensible, then reaching a consensus is a much more accurate and appropriate approach. Critical thinking skills and a sense of self-awareness can help prevent us from using our recommendations to trigger premature debate.
* As we would do with any other area of clinical practice, schools of nursing need to review the (gerontology-related) credentials and experience of the faculty before determining who would be the most appropriate appointee(s) to teach the presence and application of these concepts to students. Regardless of how prepared a school feels to enter the venture of teaching gerontological nursing (GN) principles, Ebersole (1999) reminds us that we can thank the phenomenal "dynamic duo" of the John A. Hartford Foundation Institute for Geriatric Nursing - Mathy Mezey, EdD, RN, FAAN, FGSA and Terry Fulmer, RN, PhD, FAAN, FGSA- for spearheading the movement to prepare faculty and develop curricula that are then positioned to advance the scientific practice of GN.
* As would be the case with every other area of clinical practice, GN educators also need the academic freedom to shape their students' learning activities according to scientific principles as weli as professional standards (Douglass, Atchley, David, & Wendt, 1997; National Gerontological Nursing Association [NGNA], 1995; Wendt, Peterson, & Douglass, 1993). Burke and Sherman (1993), Heine (1993), and Tagliareni and Marckx (1997) have shown how and why certain kinds of clinical settings also are recommended as the locations that are the most effective in successful application of certain gerontological concepts.
* When a school's curriculum structure reflects a vertical thread for integrating GN principles within one or more specific courses, compliance with Association for Gerontology in Higher Education (AGHE) standards (Douglass et al., 1997; Wendt et al, 1993) and NGNA (1995) standards can be a relatively concrete process for GN faculty. Here, a series of dilemmas exist that center on assuring that the content in the curriculum is arranged according to a theoretical framework, moves from simple to complex, is thorough and comprehensive without being redundant, and correlates with the level of complexity of related academic concepts that are being studied concurrently.
However, when a school threads these principles throughout its curriculum horizontally it still needs to preserve a later segment of specific vertically integrated gerontology concepts. Otherwise, Wykle and Musil (1995) alert us that:
without an opportunity to revisit the health care needs of older adults at a later stage in their educational preparation, students may underestimate the complexity of planning care for older adults. Thus, rather than recognizing how health and capability are balanced with decreasing physiologic resilience in elderly adults, some students will conceptualize geriatric nursing as no more than skills and tasks to be performed on the old or infirm (p. 39).
An additional dilemma with this decentralized format is the concern that the nebulous accountability for upholding GN principles may limit the program's ability to document student outcomes according to AHGE and NGNA standards.
* As the profession of nursing continues its internal dialogue about academic preparation for entry into clinical practice, proactive administrators also will be adjusting job descriptions in their clinical settings to reflect emerging themes in the literature regarding scope of practice. Knowing that there is a difference in the clinical priorities of nurses according to their practice (as it relates to primary, secondary, or tertiary prevention), gerontological nurses will need to lead this evolution with a focus on nursing research. This will empower our educational adjustments in future clinical experiences to be based on the state of the science in gerontology and in nursing.
Burke, M., & Sherman, S. (Eds.). (1993). Gerontological nursing: Issues and opportunities for the twenty-first century. New York: National League for Nursing.
Douglass, E.B., Atchley, R.C., David, D.D., & Wendt, P.F. (Eds.). (1997). Standards and guidelines for gerontology programs (3rd ed.). Washington, DC: Association for Gerontology in Higher Education.
Ebersole, P. (1999). The dynamic duo: Mathy Mezey, EdD, RN, FAAN, FGSA and Terry Fulmer, RN, PhD, FAAN, FSGA. Geriatric Nursing, 20(2), 106-107.
Heine, C. (Ed.)- (1993). Determining the future of gerontological nursing education: Partnerships between education and practice. New York: National League for Nursing.
National Gerontological Nursing Association. (1995). NGNA core curriculum for gerontological nurses. St. Louis: Mosby.
Tagliareni, M.E., & Marckx, B.B. (Eds.). (1997). Teaching in the community: Preparing nurses for the twenty-first century. New York: National League for Nursing.
Wendt, P.F., Peterson, D.A., & Douglass, E.B. (1993). Core principles and outcomes of gerontology, geriatrics, and aging studies instruction. Washington, DC: Association for Gerontology in Higher Education.
Wykle, M.L., Sc Musil, C.M. (1995). Expanding clinical experiences. In XT. Fulmer & M. Marzo (Eds.), Strengthening geriatric nursing education. New York: Springer.
Barbara Hassinger Conforti, MSN, RN, CS, CRNP
Faculty - Gerontology
Lancaster Institute for Health Education
School of Nursing
Exposure to well elderly individuals not just the institutionalized population is vital to the understanding of the geriatric field. This would help break the stereotypical notion that elderly individuals are frail, helpless, and do not contribute to society.
Clinical experiences at elder social centers that perform wellness screenings and Alzheimer's day treatment facilities can show a spectrum of the elderly population.
Patricia Reilly Butcher, BS, RNC, CRRN, CCM
Senior Case Manager
Concentra Managed Care
This question was submitted by Joan Kramer, PhD, RN, Infection Control Coordinator, Johns Hopkins Medical Services Corporation, Baltimore, Maryland. Her commentary follows:
It is not uncommon for associate and baccalaureate nursing programs to arrange students' first clinical experiences in nursing homes, where the opportunity to practice basic activities of daily living (ADLs) skills is abundant. As one respondent observed, it also is a way for students to gain comfort with communication skills in an environment where clients often are "grateful and nonjudgmental." These are good experiences for students, but if geriatric care is not revisited at a higher level in the program, it may leave students with the impression that geriatric care is routine, uninteresting, and uncomplicated. The degree to which a geriatric component is incorporated into a nursing program is, of course, highly dependent on the length of the program and the design of the entire curriculum.
As a Clinical Nurse Specialist in a nursing home, I arranged student placements for a variety of nursing programs for many years. It was difficult to convince schools to bring senior-level students to nursing homes for advanced clinical or leadership rotations. The reasons for this may be twofold. Instructors with little or no experience in longterm care (LTC) may not know what these settings can offer students. From the student perspective, there is the allure of the "high tech," fast-paced acute care environment and the belief that such experience is essential to their learning. Yet, LTC settings are rich in the very experiences that can provide a strong framework for future nursing practice in any setting. In LTC settings, the focus is squarely on nursing care as the key component to successful patient outcomes. Among the components of nursing care practiced daily in LTC are interdisciplinary care planning that includes families and residents, restorative care programs to maintain and promote function, chronic disease management, end-of-life care, prevention, communication with individuals with a variety of communication deficits, comprehensive physical and psychosocial assessment skills, and patient/family education. The LTC setting provides the opportunity to learn how to "do with" rather than "do to" geriatric patients. In addition, the LTC setting can provide senior-level students with valuable lessons in the management of the care environment including managing many patients with few nurses and a large nonprofessional staff, delegating, resolving conflicts, educating staff, motivating others, and achieving compliance with an incredible array of regulatory standards.
Given that nursing homes are admitting patients with more acute care needs than ever before, these settings also afford students exposure to higher-level skills such as intravenous management, administration of blood components, ventilator care, complex wound management, and dialysis to name a few. Students can learn first-hand the highly independent assessment and decision-making skills required in an environment that frequently does not have a physician staff immediately at hand.
Because most of the large cohort of aging Americans will "age in place" in their homes and communities, it is important for students to be exposed to nursing elderly people in their homes, and in assisted living facilities, foster care, retirement communities, senior centers, adult day care centers, and managed care settings. These settings highlight the wellness and prevention concepts critical to successful aging.
Respondents have offered a variety of practical ways to incorporate clinical experiences with elderly people into an undergraduate curriculum. The American Association of Colleges of Nursing (1998) published a consensus statement on the core content, competencies, and teaching strategies that will bring baccalaureate nursing education in line with the needs of the 21st century. Attention to the needs of the aging population, prevention, chronic disease management, and skills for a variety of care settings is central to this population. For now, whether in nursing homes, rehabilitation centers, their homes, or communities, faculty and LTC nurses need to be interpreters of the geriatric experience for students. Geriatric care experiences should not be considered solely as an introduction to ADLs, or as a way to practice IPRs, but as a well-integrated component of the undergraduate educational experience.
American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.