Radical changes in the practice of nursing are occurring (Fulmer & Abraham, 1998). These changes mandate that new concepts and strategies be incorporated into nursing education.
CHANGES IN NURSING PRACTICE
Increase in Numbers of Older Adult Cohorts
The first change involves the increase in numbers in older adult cohorts (Kresevic et al., 1998). Based on these demographic trends, concepts of gerontological nursing care must be part of a nursing curriculum. Friedan (1993) has challenged health care practitioners to revolutionize their perspective about the health care needs of older adults. Because old age is not a "curable" condition, the traditional "medical model" is not a sufficient theoretical foundation for gerontological nursing care.
During the feminist revolution of the 1960s, society was stimulated to perceive and treat women in a different way. Friedan (1993) has suggested a similar revolution must occur with respect to perceptions of older adults in our society (including the health care system). The perception of "age as disease" must be more thoroughly relinquished - then older adults will become free from being perceived as "objects of care" (Friedan, 1993). A focus on function, rather than cure, is the primary need for older adult individuals. Although such a focus is not new to nursing, it is often overshadowed by high technological and more exciting, fast paced components of the health care system. Thus, concepts and strategies of function and maintenance must be highlighted in nursing curricula to reflect an appropriate focus.
Acuity Versus Chronicity
A second change in nursing curriculum involves issues of acuity versus chronicity. The majority of health care needs of the older adult tend to be chronic in nature (Ebersole & Hess, 1998). Although all individuals may face acute illness and hospital-based care during the life span, health care appears to be progressively moving away from institutionalized care toward community-based care. Consequently, nursing practice is increasingly moving outside of acute care facilities or nursing homes into the community environment. This is especially true for older adults. It is estimated that only 5% of the older adult population is in an institution such as a hospital or nursing home (American Association of Retired Persons, 1998; Lueckenotte, 2000), with the rest residing in the community. The trend toward "aging in place" or remaining in one's own home or the community is a sought after goal for older adults (Mollica, 1998).
Population Based Policy Developments
A third change effecting nursing curricula results from population based policy developments. A potential Medicare reform suggested by the American Nurses Association includes programs of preventive care, early intervention, and case management services (Gross & Reed, 1999). Contemporary nursing students need skills, such as case management, that are more comprehensive from what was needed in the recent past.
According to Diwan (1999), case management evolved in the early 1970s as a way to match clients to appropriate services, using assessment, care plans, coordination, and arrangement of home or community-based services for long-term care patients. Case management is quickly becoming a requisite skill for nurses. Netting et al. (1997) stated, "There are few health professionals who will graduate and enter a system that does not use case managers in some way" (p. 143). Consequently, case management skills for older adults are an essential component in undergraduate nursing curriculum.
Educating Nurses to Work with Changing Needs
To be current, nursing education must reflect the changes in health care which have resulted from changes in society. Nursing models of learning are addressing these changes. By adding the concept of adaptation to Benner's (1984) model of professional development, Neal (1999) suggests that nursing students need to learn how to function in unstructured settings. Nursing faculty must address this need by developing learning experiences based on the extant health care needs of society and those needs anticipated for the future. Thus, new models of learning in health care should be a fundamental consideration in nursing curricula.
Nursing education never remains static. This is particularly true within the arena of gerontological nursing. A focus on aging poses special challenges to health care faculty. Very few faculty have gerontological education, yet they are asked to teach this content (Burggraf & Barry, 1998; Gueldner et al-, 1995; Bahr, 1987). This being the case, nursing faculty with expertise in the field of aging have the responsibility of mentoring their colleagues to address the need for increased emphasis on gerontological nursing education.
Although students have conducted well-family home visits in community nursing or public health courses for quite some time, these experiences may lack appropriate gerontological underpinnings. Methods to recognize and work with the changing needs of older adult populations must be addressed in nursing education. An innovative clinical learning activity was developed to concentrate on the needs described previously. The purpose of this article is to describe a clinical learning activity, implemented by an undergraduate nursing faculty teaching team, to educate students about the health needs of older adults.
OVERALL SCHEAAA OF THE COURSE
The clinical learning activity described in this article is part of the required course, Nursing Care of the Mature Family, taught at the Medical College of Georgia School of Nursing at Athens. The faculty providing the in-depth gerontological teaching in this course have a strong gerontological research and community clinical background. To help maintain and enhance the course, the School of Nursing administration supported faculty participation in the John A. Hartford Foundation Institute for Geriatric Nursing Partners Program for Dissemination of Best Nursing Practices in Care of Older Adults. The course described in this article has been taught for the past 5 years as a semester course, with approximately 300 students completing the course. A similar course was taught prior to this on a quarter system.
Didactic content of the course reflects what is often encountered in the home visit clinical learning activity that occurs during the first half of the course. Other clinical learning activities are included in the course, but are not described in this article. The course is taken during the junior year as part of total curriculum that covers the life span. Although many complex issues are covered, students are provided the opportunity early in their student trajectory to develop communication skills, understand the importance of community environments, and learn the basic premises of gerontology. All of these skills build a solid foundation for their later courses, many of which involve older adults. Faculty interested in initiating a gerontologies! nursing course might find the resources by the American Association of Colleges of Nursing and the John A. Hartford Foundation Institute for Geriatric Nursing Older Adults (2000), Luggen and Meiner (2000), and Mariano, Shelkey, Gould, Mezey, and Fulmer (2000) helpful.
DESCRIPTION OF THE GERONTOLOCICAL CLINICAL LEARNING ACTIVITY
The goals of this clinical learning activity are described in the Table. This clinical learning activity is composed of approximately eight weekly home visits with a resident of a local housing authority, clinical conferences, interdisciplinary and intradisciplinary consultation efforts, referral activities, and family consultation. The professional staff of the local housing authority identifies older families or individuals who might benefit from home visits by a nursing student. Verbal consent to participate in this clinical learning activity is then obtained by the Housing Authority staff.
The first clinical day is primarily concerned with orientation. Students obtain an understanding of this community agency through an on-site orientation and a presentation by the Social Service Director of the Housing Authority. During the orientation, students have an opportunity to meet the residents who have volunteered to participate in the program, and appointments are made for the first home visit.
On the first day of class, the students also receive an orientation to community nursing and the process of home visitation. The personal contact in the client's home is instrumental in facilitating students' understanding of the functional level of older clients. The home setting offers advantages to both the client and the student. The client is relieved of the stress of arranging transportation for services. The atmosphere tends to be more relaxed than in a clinic setting and more conducive to open and honest communication with the student because the client is in control of the environment. From the nursing point of view, the students can assess the home in terms of support, quality of family and social interactions, and safety and home hazards. Observations allow for care plans to be individualized for the client and family and tend to be more realistic than those developed without cognizance of the home environment.
STUDENT LEARNING GOALS IN THE GERONTOLOGICAL CLINICAL LEARNING ACTIVITY
Students are responsible for initiating the home visits. A multidimensional health assessment is conducted during the first few weekly visits. Areas included in the assessment are cognition, health history, function, nutrition, medication, family, environment, and development. Students are also responsible for completing a weekly clinical update and case management form. Similar to a traditional care plan, this form assists the student in structuring their implementation of the nursing process with the client. Specific examples of issues addressed in this form include the problems or potential problems (which may change as the student obtains more data), projected plans for tasks for the next home visit, identification of shortterm and long-term goals, nursing interventions, and methods of evaluation. The faculty has found the form useful in guiding students. A student might need to conduct a more indepth assessment in a specific area, talk with other care or service providers, or obtain health information for a teaching intervention. The form provides structure for the student and prompts the student to efficiently use the nursing process.
A weekly clinical conference is an integral component of this clinical learning activity, providing an opportunity for students to analyze the findings obtained from their assessments. Each student provides a brief update on the progress or lack of progress in the home visit. Students are encouraged to consider the clinical conference report much like the nursing report that occurs during a hospital shift change or a care plan conference in a nursing home.
Using group dynamics, the faculty member guides the clinical group in exploring the problems presented by each student. To foster group dynamics, the faculty member responds to questions or requests for help by first letting the student group attempt to provide answers or insight. Initially, the faculty member may need to prompt the group with questions such as, "What would the group suggest?" However, with the development of skills over time, student group members often automatically offer suggestions without the faculty member asking for their opinion. This phenomenon helps the student understand the importance of collégial consultation. The clinical conference also provides an opportunity for students to obtain input and guidance for the development of a nursing intervention.
Case Management Modeling
There are no on-site nurse case managers at the housing authority. However, the student actualizes the case manager role during the 8-week clinical learning activity, with the guidance of the clinical faculty member. Faculty provide guidance and modeling of the case management role in the weekly clinical conference, individual conferences, and home visits, as needed. Additionally, a class is taught early in the semester that provides the underpinnings of the case management. After the initial assessment is complete, students identify problems or potential problems and interventions that they may address with the client. Examples of possible clinical learning scenarios follow.
Scenario 1. As a weekly home visit was concluding, the student asked the client if there were any additional questions. Because rapport had been established, the client informed the student that she had been worried about some green colored vaginal discharge. Even though the client had been regularly visiting a physician for another health care problem, she had been afraid to discuss the matter with the physician because he might think she was a "loose" woman. The student successfully encouraged the client to reconsider seeking medical advice. During a subsequent medical examination, the client was noted to have a suspicious Pap smear. Cervical biopsy was scheduled that confirmed the presence of abnormal cells. The woman underwent an abdominal hysterectomy, followed by chemotherapy and had a good prognosis.
Scenario 2. For a number of years, one of the clients used a wheelchair because of an above the knee amputation. After establishing a relationship with him, the student found out that the client wished he could get out of the wheelchair and walk. He had never owned a prosthesis. The student decided to see if she could help him obtain one. She found out that the client was a veteran and, with much diligent effort, she was able to procure a prosthesis for the client by the end of the semester. The client's family had also taken his handicapped parking permit and would not return it. The student was also able to get this problem corrected and obtain a new handicapped parking permit for the client. Needless to say, the quality of this client's life was greatly improved through his relationship with this nursing student during extended clinical visitations.
Scenario 3. An elderly client had dipped snuff since she was a young girl. It was a habit so strongly ingrained that the client was not willing to give up. The student was concerned that the client may develop cancer of the oral pharynx. At the beginning of the relationship, the client was not willing to even talk about the dangers of her snuff use or possible ways to quit. After establishing a relationship with the client and gaining her trust, the student was able to introduce the client to an alternative, mint snuff. This snuff is made of mint leaves, which satisfy the need for something to chew, while at the same time decreasing the chance of developing oral pharyngeal cancer. Initially, the client cautiously agreed to try the mint snuff. The student continued to encourage the client to use the mint snuff throughout her clinical experience. By the end of 8 weeks, the client reported that she was happy with the mint snuff and would change permanently. If this student had not had the extended time to establish a relationship with this client and encourage her on a continual basis, this potentially life saving change may not have occurred.
Scenario 4. An elderly client with congestive heart failure and a history of several heart attacks was on numerous medications for her heart. Of late, the client had complained of increased shortness of breath and had started using oxygen at home. One of the client's medications was furosemide (Lasix) to be taken twice a day, which the client was taking at 9 a.m. and 9 p.m. When assessing the client's medications and how she used them, the student realized that the client was only taking Lasix in the morning because it kept her up all night if she took the evening dose at bedtime as prescribed. The student instructed the client that by taking her evening dose a little earlier at 6 p.m. instead of 9 p.m., she would be able to get the benefits of the medication without loosing any sleep. The client started doing as the student instructed. By the end of the semester, the client was no longer complaining of shortness of breath and no longer needed the supplemental oxygen at home. Her ability to perform activities had also improved.
Scenario 5. One student had the opportunity to work with an elderly man who was of an ethnic background different than her own. The client had a long history of hypertension and heart disease. One of the problems identified by the student was that the client ate a diet high in fat and salt. After several attempts to assist him in changing his eating pattern, the student became very frustrated and decided that it was of no use to provide dietary education to him, and decided to work on other problem areas. After reading about several nursing theories, the student became very interested in Leininger's (1979) cultural care theory. The student was enlightened about her client's resistance to change his diet in such a drastic way. Applying Leininger's theory, she then reassessed her approach and made some changes, incorporating the client's culture with new interventions to reduce his sodium and fat. The client was satisfied, thus, more compliant with the diet regimen.
Clinical Synthesis Paper
The final phase of the clinical learning activity includes a formal clinical synthesis paper. Students are required to identify a theory or a concept used to guide their clinical practice. Faculty encourage students to identify a theory as early as possible in the semester. The paper also addresses an assessment of the client/family system, problems and strengths, interventions, and evaluation (or proposed evaluation, if limited by time). In the paper, the student synthesizes the process of their clinical activities and thought processes used throughout the semester. Formative evaluation is ongoing through the semester in terms of the weekly clinical conference. Summative evaluation is accomplished with the outcome of the final paper.
A major outcome of this clinical learning activity is the opportunity for students to become familiar with the most significant health needs of older adults. This clinical learning activity provides the necessary experience for the development and implementation of age-appropriate nursing interventions with older adults. Students obtain experience on all levels of prevention and the maintenance of function in this population. The focus of gerontological nursing is on the support of function, rather than disease (Whall, 1999). With the experiences students obtain in this course, they become better prepared to meet the health care needs of an aging population.
Often issues of compliance or adherence are a challenge with this population of clients. Many of the primary health problems uncovered by students involve behavior change. Students learn that a longitudinal interaction is often needed with nursing interventions that address many of the major health problems in United States. Using theories such as Prochaska's (1994) developmental model of behavior change, students learn about the many small steps required to assist an individual in smoking cessation or implementing an exercise program (Ebersol & Hess, 1998). While students plan interventions with clients, they simultaneously learn how to support and empower clients to make a change. Students have the opportunity to learn that knowledge is necessary, but not sufficient, for behavior change (Haber, 1994). In gerontological nursing, an advocacy approach is more of a priority than a prescriptive approach (Whall, 1999). This clinical learning activity provides the student with the opportunity to practice an advocacy approach.
Although students are not involved in hospital-based activities in this particular clinical learning activity, students have stated that this clinical learning activity has providing them with a better understanding of the care of hospitalized older patients. High levels of hospital readmission can be a problem for older adults with chronic diseases. This phenomenon may leave the student wondering why readmission occurs and with questions related to adherence. Conducting in-home assessments and care helps the students ascertain many home-environment factors influencing older adults and begin to understand why individuals may not adhere to health care regimens. In the future, this knowledge will help the student conduct better hospital discharge teaching and develop better hospital discharge plans for older adults.
Another learning outcome of this clinical learning activity is the opportunity to conduct in-depth assessments of the older adult over time. Schultz, Geary, Casey, and Fournier (1997) have suggested the importance of collecting health information from an older adult over time, rather than at a single point in time. Students have made comments about how they now understand the complexities of older adult health concerns and that a "snap shot" assessment of an older adult's health status, as usually obtained in a hospital, is insufficient.
Additionally, having the opportunity for several visits allows students the time needed to develop rapport with an older adult. This results in the exchange of insightful information that might not be obtained in a fewer number of visits. For example, on one occasion when a client with severe arthritis fell in her apartment, she telephoned "her nurse" at school, to tell the student that she needed assistance. The student contacted the building manager to request that someone check the client to see if she had sustained an injury. No serious injury was noted.
Critical thinking skills and problem solving skills that are age-appropriate for older adults are used in this clinical learning activity. Students are supplied with a preliminary packet of assessment tools prior to the first home visit. Often, students discover they need more specific or additional information than what is required in the initial packet. With guidance from clinical faculty, students take the approach suggested by Schultz et al. (1997), of "branching out the assessment" when a problem is uncovered. In addition to learning about the array of potential assessment instruments, students also learn the process of thinking through other methods of obtaining information. Students learn that family members, friends, or other service providers are often founts of helpful information.
Critical Thinking Skills
Critical thinking is further enhanced when students uncover problems. After a problem or a potential problem is identified, students discuss the issue in clinical conference. Their student colleagues, in conjunction with the faculty member, assist in "brain storming" and the developing plans for interventions. This critical thinking component and subsequent interventions often provide exposure to multidisciplinary learning experiences.
A major intervention component often involves consultation or referral to other nurses or other professionals. With the guidance of the clinical faculty, students must think through the referral process. After the appropriate referral is identified, students may encounter resistance from the client. In response to this resistance, students learn how to support and encourage the client in making the initial encounter. For example, clients have often been reluctant to report a symptom to their primary care provider. Another example is a client in need of increased health care monitoring benefiting from attending an adult day care center. Older adults may be reluctant to take such action. Clients may confuse an adult day care center or a personal care home with a nursing home, and consequently manifest a great deal of fear and trepidation. The students learn how to educate, encourage, and support the older adult in the health-seeking behavior of acquiring more services, which will enable him or her to maintain their health.
Developing communication skills with older adults is an outcome of this clinical learning activity. Although most students come into the course with some background and ability in communication skills, clinical practice with older adults poses special communication challenges (Haber, 1994). The ability to communicate effectively is a prerequisite for the practice of health care, yet the acquisition of these skills can be difficult. A limited focus on accomplishing tasks of "doing something to the patient" allows the students to focus on the process aspects of care (Elsner, Quinn, Fanning, Gueldner, & Poon, 1999) and the vital skill of communication.
Clark (1997) stated,
The metaphor of the reflective practitioner has been proposed for one who develops an appreciation for those gray areas of clinical practice where value conflicts and moral dilemmas are encountered and where the true artistry of professional practice is evident (p. 448).
The development of the "inner ear" (Clark, 1997) is enhanced by the clinical learning activity.
Different Nursing Perspective
Perhaps the most salient outcome of this clinical learning activity is the opportunity for students to see a different perspective of nursing. Students are provided with the basis from which to develop a valid point of view related to gerontological nursing. Fulmer and Abraham (1998) have suggested that a "major shift in nursing practice from disease management to health promotion is much needed for this age group" (p. 388). At first, students are often at a loss for what to do. Statements such as, "There are no problems to fix with this client," are common. There are limited psychomotor skills involved in this clinical activity, which may cause students initially to wonder what their "tasks" are. However, this phenomenon helps students understand the insufficiency of the medical model as a basis for providing care for older adults.
Typically by the middle of the home visit sequence, students realize that there is much to do to help the client maintain function or to promote health. Students reap the reward of learning principles of tertiary prevention and extending the active life expectancy of these clients (Mantón Qc Stallard, 1990). By the end of the clinical learning activity, students are often surprised by the amount of nursing care needed by the client. Students typically perceive that they made a difference in the life of an older adult. A promising byproduct is a greater of understanding of the health needs of older adults and the opportunity to use gerontological skills that will be needed in their future practice as RNs.
Although nursing care of all age groups is holistic, perhaps nursing care of older adults requires the most rigorous holistic perspective. The older adult group, as compared to children, young adults, or middleaged adults, is the most heterogeneous age group (Neugarten, 1978). Older adults are more complex because of their history of longevity, as compared to younger age groups. Thus, a gerontological perspective requires less of a reductionist philosophy and more of a holistic philosophy (Clark, 1997). Burggraf and Barry (1998) have suggested that nurse educators of the 21st century must focus on wellness and health promotion rather than illness. Using clinical learning activities such as those described in this article, will assist nursing faculty to prepare students to meet the health needs of our aging society.
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STUDENT LEARNING GOALS IN THE GERONTOLOGICAL CLINICAL LEARNING ACTIVITY