It is common practice for beginning nursing students to have some of their first clinical experiences with elderly clients. The clinical experience may take place in a long-term care facility where students practice basic hygiene techniques, assessment, communication, and charting. There are several advantages to this setting. The nursing care required by the client is less demanding and threatening to the student than that of the acute care client. Generally, the client welcomes the student's attentions and thus provides a more relaxed atmosphere for the students practice.
Other health care settings frequented by the elderly may also be used. Colleagues at the University of Iowa implemented and maintained student experiences in well elderly screening clinics for over ten years; they continue to evaluate and revise these experiences aimed at developing psychomotor assessment skills (Crowell, Freel & Hart, 1978; Gumming & Crowell, 1982; Miller, Tedford & Lehmann, 1981).
Contact with the elderly client early in the nursing career may assist the student in reducing some negative stereotypes toward aging. Heller and Walsh (1976) found that frequently planned experiences through student field trips to facilities for the aged and home visits by students changed attitudes in a positive direction toward older people. Hart, Freel and Crowell (1976) found that students' attitudes significantly improved following structured interviewing contacts with several well elderly clients. Francis (1978) utilized well elderly clients in a senior citizen apartment complex for senior nursing experience. Students were felt to have developed positive attitudes toward the elderly as a result of the experience and also to have gained experience with a variety of nursing skills.
The focus of our student experiences with the well elderly is somewhat different from the approaches used by our colleagues mentioned above. Faculty at Grand View College designed a unique year-long clinical experience to increase students' contact with the elderly. We chose to have each sophomore student follow one elderly client in the home environment over a period of two semesters to practice communication and assessment skills and to provide a socialization experience. This one-on-one pairing approach facilitated rapport building and allowed the student to view the individual in a holistic manner. We hoped that the personal contact with one elderly person over a period of time would facilitate integration, differentiation, and internalizing of positive attitudes toward aging. Thirty-three beginning nursing students participated in the pairing experience. The clients were well elderly persons living in one of three residences for the elderly. All students carried out the same specific assignments at intervals of approximately thre« weeks.
Objectives of the Experience
Besides facilitating social interaction and positive attitudes toward the elderly, the assignments were designed to meet the following objectives:
1. Demonstrate effective communication skills.
2. Identify the client's perceptions of health and illness including the internal and external variables which affected the level of health.
3. Identify to what degree the individual was meeting normal developmental tasks for his age.
4. Collect and record a nursing history.
5. Perform and record data on selected assessment skills.
6. Practice taking vital signs.
7. Develop and implement a teaching project on health promotion based on the client's need for health teaching.
Faculty met with staff in each facility prior to the experience to discuss feasibility, interpret goals, and explain implementation mechanisms. Contracts similar to those used with other clinical agencies were developed and signed.
Each of the residences varied slightly. One facility used was a 50-bed residential care agency. Residents were given minimal assistance with daily living activities by non-professional staff; supervision was provided for medication administration if necessary and residents ate all meals in the facility^ dining room. Transportation for shopping and recreational excursions was available.
The second facility used was a 106-unit independent living apartment building for the elderly. Residents were not provided with health care except on an emergency basis. Recreational activities and transportation for shopping were available and residents could purchase the noon meal in a community dining room if they desired.
The third facility was a ISO-unit highrise apartment building for the elderly. Recreational activities, transportation, and meals were available on an optional basis. There were no health services available, hut there was access to administrative staff at any time during the day.
One person in each agency, usually an activities coordinator, was designated the liaison person to vork with faculty in monitoring the experience. This liaison person was responsible for suggesting potential residents for the pairing experience according to faculty-determined criteria, contacting and interpreting the experience to the resident, and gaining permission for the pairing. To be selected for the experience, the resident needed to be essentially "well," i.e., able to communicate without difficulty, be oriented to reality, have minimal ambulation problems, and to be free of acute health problems. All residents were over 62 years of age; the majority were female.
Each resident who agreed signed a permit form which specified the time span over which the visits would occur, indicated the nature of the visits and clinical practice, identified the client's right to withhold participation in any portions of the sessions, and to cancel the relationship at any time. The permits were then returned to the college. Clients were reminded that the student did not replace their usual health care provider.
Clients were assigned to students shortly after the beginning of the fall semester. Each student was asked to arrange a halfhour initial visit for purposes of introduction, socialization, and interpretation of future visits. Students then made visits at intervals as assigned to meet the objectives of the experience, and at a time mutually convenient to both student and client rather than at a specific class time.
After the initial orientation visit, students progressed to taking a health history, interviewing the client about perceptions of health and illness, assessment practice and a teaching project. The physical assessment practice, carried out after the student had learned it in a lab session, included assessing eyes, face and neck, integument, musculoskeletal system, heart and lungs, and abdomen. Mental status was also assessed. All assessment findings were recorded on a pre-printed form provided by faculty. Assessment findings were compared with developmental changes expected for that age group. At each visit students checked vital signs and practiced communication skills for later analysis. For the teaching project, students identified such learning needs as skin care, exercise, and nutrition, and wrote goals and methodology to meet the need. Some students developed elaborate audio and visual materials to aid in doing the teaching. All teaching was done one-on-one with clients and learning was evaluated at the end of the visit.
Evaluation was both ongoing and terminal. Because faculty were not in attendance during the students' visits, discussions throughout the school year provided for feedback and helped to clarify observations. Assessment papers were read by faculty and returned to students with appropriate comments.
Following the experience, students and clients were asked to complete separate evaluation questionnaires. Clients answered questions regarding how they felt about the experience, while students evaluated the learning experiences and their attitudes toward the elderly. Approximately two thirds of the clients returned the questionnaires. Most of the clients had previous contact with nursing students in hospitals and physician offices; only two had no previous student contact. They described their feelings both prior to and following the experience through an adjective checklist. A few of the elderly felt anxious before the interactions began; these numbers did not change appreciably at its conclusion. Over 90% of the elderly indicated they felt comfortable with each assignment.
The student return rate for completed questionnaires was 94% (31). All but one student had previous contact with elderly people through grandparents, work experience, friends or church. Students were asked to check adjectives that corresponded to feelings pre- and post-assignments. In contrast to a limited number of elderly indicating anxiety before the experience, ten students (32%) indicated feeling anxious when the elderly pairing was first announced and only one still felt anxious at the end. At the beginning of the semester over a third of the students felt they would learn a lot from the assignment; after the experience the number of students responding, "I have learned a lot," doubled.
Students completed an adjective check list that described attitudes toward the elderly pre- and post-experience. Positive and negative adjectives inclusive of myths and stereotypes made up the list. Some interesting results were seen. The number who felt the elderly were frequently ill dropped from nine (29% ) before the experience to three (9%) after the experience. Twelve students (39% ) felt the elderly were stubborn before the interactions; only four (13%) continued to have that attitude at the conclusion.
The most dramatic changes were seen with the positive adjectives. The number of students who felt that elderly learn new things increased from four (13%) to 14 (45%). Those who felt the elderly were in good health changed from two (6%) to ten (32%). Those who indicated the elderly are outgoing rose from six (19%) to 20 (65%). The number who checked the adjective 'independent' changed from ten (32%) to 16 (52%). Most students (947r) felt elderly people are friendly; this did not change following the experience.
Students evaluated each of the assignments on a scale of 1 to 3, with l = no value, 2 = some value, and 3 = very valuable. All students found the communication assignments were of some value (29%) or very valuable (71%). Only one student regarded the health/illness and health history interviews as being of no value. The rest indicated the assignments were of some value or very valuable. All but two felt taking vital signs was of value. Over 70% gave assessment practice a very valuable rating while more than 90% of the students found every assignment, including the teaching project which was the most popular, to be either of some value or very valuable.
Evaluation meetings were held between agency liaisons and faculty members to discuss the experience. Some of the problems which existed included clients taking extended trips out of town, becoming ill or hospitalized. Students were not able to meet deadlines for assignments because of these situations. Several clients were found to have chronic illnesses which were not well controlled and one elderly man had an emotional disorder which was controlled by tranquilizers. These situations made it difficult for the student to focus on the well elderly, and in the case of the emotional disorder, communication was occasionally distorted. A few clients, in spite of the disclaimer given at the beginning of the experience, viewed the student experience as a replacement for their regular health care. Faculty also observed that the physical assessments carried out in the individual clients apartments made it difficult for faculty to validate student findings.
Several benefits came from this experience. Our students provided a positive image of nursing to a population who may think of nursing as illness-oriented. The faculty also found themselves in an informal consultant role during liaison meetings. When questions about specific health problems arose, we were able to refer them to other health professionals or answer them ourselves.
In the future, the faculty plans the following changes in the experience:
1. Meet with agency Liaisons to review potential clients and screen them for health problems and other situations that might interfere with successful visits.
2. Meet with the selected clients in group sessions prior to the first assignment and review the intent of the experiences.
3. Supervise physical assessment in a group so that faculty can validate findings more easily.
The pairing of beginning nursing students with well elderly clients was a very worthwhile experience that will be retained in our curriculum. Very few clients dropped out of the program. The assignments were appropriate for the leve! of the student and the elderly clients felt comfortable with the interactions. Although a formal research study was not conducted, students did indicate more positive attitudes toward elderly people following the experience. We hope this experience will provide a foundation to build upon as students next work with ill elderly clients in agencies such as hospitals and nursing homes.
- Crowell, C.. Freel, M-. & Hart, L. (1978) Developing assessment clinics for the elderly. Journal of Gerontological Nursing, 4(4), 40-48.
- Cunning, B., & Crowell, C. (1982). Well elderly screening clinics: A community clinical experience in health assessment. Jour nal of Nursing Education, 2H3\ 38-48.
- Hart, L., Freel, M., & Crowell, C. 1 1976). Changing attitudes toward the aged and interest in caring for the aged. Journal of Nursing Education, 2(4), 10-16.
- Heller. B., & Walsh, F (1976). Changing nursing students' attitudes toward the aged: An experimental study. Journal of Nursing Education, J5l5i, 9-17.
- Francis, M. (1978). Need community clinical experiences? Ask the senior citizens Nurse Educator, 3, 22-24.
- Miller, S-, ledford, A., & Lehmann, .S. 11981). Identification of health problems at well elderly clinics. Journal of Gerontological Nursing, 7(3), 159-160; 167-168.