While hospital administrators have reacted to the shortage of professional nurses in acute care settings, that shortage is actually twice as severe in long-term care (Shields & Kick, 1982). Growing numbers of elderly persons, living to advanced ages, are predicted to increase the need for chronic health care services (Reif & Estes, 1989), yet concrete plans for developing such resources are notably absent. DeWitt and Matre (1988) discuss the paradox that older persons face: the elderly have the greatest need for nursing services, but relatively few nurses are willing to provide such care.
Registered nurses, the largest group of professionals involved in long-term care, are similar to other disciplines in their hesitancy to desire or to accept work with the elderly (Feldbaum & Feldbaum, 1981), leading Shields and Kick 1982 ) to suggest that the term "nursing home" is a misnomer since so few nurses choose to work in such settings. Nursing students also demonstrate reluctance to work with the elderly as evidenced by Williams, Lusk, and Kline (1986), who asserted that less than 5% of this group desire to work with the aged. Even nurse educators admit that a lack of importance is accorded to content on care of the elderly in nursing curricula - a major barrier to providing students with needed gerontologie information (Solon, Kilpatrick, & Hill, 1988).
Several reasons have been offered for the reluctance of both nurses and nursing students to work with older patients. Although it has been suggested that financial issues are the barrier to attracting nurses (Maraldo, 1988; Beck, 1988), Ebersole (1988) found that salary was the least important consideration for geriatric nurse practitioners in the nursing home setting. The National Nursing Home Survey (U.S. Department of Health and Human Services, 1985) found that, in fact, salary and benefits were rated very favorably by nurses employed in nursing homes.
The bulk of research that has attempted to explain nurses' feelings about the aged has focused on attitudes. Relationships between several variables and positive or negative attitudes have been found, including: being older and a graduate of a diploma nursing school (more positive) (Feldbaum & Feldbaum, 1981), having increased exposure in the work setting to the elderly (more negative) (Brower, 1981), being younger and having less than 10 years experience with the elderly (more positive) (Taylor & Harned, 1978), being older and having more education (more positive) (Gillis, 1973), and type of nursing position (Brower, 1985). Prior exposure to and experience with the elderly exerted a positive influence on nursing students' attitudes in studies by DeWitt and Matre (1988) and Feldbaum and Feldbaum (1981). These attitudinal studies were built on the assumption that improving negative attitudes could simultaneously stimulate the willingness and interest of nurses in working with the elderly.
Another body of research on these issues has shown that little relation exists between positive attitudes toward the elderly and actual interest in working with them. In the acute-care environment, Meyer, Hassaneine, and Bahr (1980) demonstrated that nurses with more positive attitudes toward older persons chose not to work with them. From an academic perspective, nursing students who were involved in clinical experiences with the elderly, or who received a curriculum planned to alter negative attitudes, did report more positive feelings but still had little interest in working with older persons (DeWitt & Matre, 1988; Greenhill, 1983; Gunter, 1971).
Attempts to influence the attitudes and intentions of nursing students have been made, primarily by implementing specific clinical experiences in nursing homes, hospitals, and community settings. In the nursing home setting, a two-week clinical experience caused nursing students to have increased negative feelings about work with the elderly (Cook & Pieper, 1985). A comparison of two groups of licensed practical nursing students who were placed in either a hospital or nursing home setting by Frisch (1989) revealed that the students who had clinical experiences in the nursing home reported more skill acquisition in a less hectic environment. Spier and Yurick (1989) and Taft (1986) claim that early educational exposure to the well elderly will foster more positive attitudes, an assumption partially tested by both Eddy (1986) and Heller and Walsh (1976). These researchers found that experiences with well elderly clients did foster more positive attitudes in students (Eddy), and even exerted a positive influence on the work intentions of associate degree students (Heller & Walsh).
Statement of the Problem
Prior investigations have led to conflicting and somewhat ambiguous findings on factors that influence nurses' work preferences in relation to the elderly. This study was designed to investigate the effects of two different types of clinical experiences on the intentions of nursing students to work with elderly patients since some support for the ability of educational experiences to exert a positive influence exists (Eddy, 1986; Heller & Walsh, 1976). Given the belief that exposure to the well elderly encourages students to view gerontologie nursing more positively (Spier & Yurick, 1989; Taft, 1986), the following hypothesis was proposed:
* Nursing students will express greater intent to work with older clients after completion of a clinical experience with well elderly persons living independently than after completion of a clinical experience with ill elderly persons in a nursing home.
Prior to involving students in this research, consent was obtained from the Institutional Review Board to conduct the investigation. Baccalaureate nursing students at a large state university who were enrolled in "Nursing Care of the Elderly," a required core course taken during the first semester of the junior year, comprised the study population. On the first day of class, the general purpose of the study was explained to the students and the voluntary, anonymous nature of participation stressed. In all, 39 students elected to be involved in all three phases of the study, representing an 83% completion rate.
The "Nursing Care of the Elderly* course lasted 15 weeks and consisted of 21^ hours per week of didactic content on nursing of the older adult in conjunction with six hours per week of structured clinical experiences with elderly clients. During the first seven weeks, students participated in clinical experiences in a skilled care facility where they were expected to provide routine nursing care for one or two patients. During the second seven weeks, students were assigned to provide care for an elderly person living independently in a high-rise apartment complex specifically designed for the elderly. These older individuals had been identified by the apartment manager as healthy but with a variety of care needs that ranged from medication instruction to insulin administration.
The course was taught by a nurse with a graduate degree and certification in geriatric nursing. Instructors in the clinical portion of the course were persons who specifically expressed interest in and satisfaction with working with the older population.
Initial analysis of the sample characteristics (Table 1) revealed study participants to be primarily young adult females who were traditional (first career) students with past but not current work experience with older individuals. These students reported positive relationships with older persons and were equally divided on having had exposure to family care-giving situations.
The study instrument used to assess the work preferences of students was synthesized from items on the Nursing Specialty Preference (Delora & Moses, 1969) and the Work Preference Instrument (Wilenski & Bismark, 1966). In all, six items were used in four categories to measure student intentions. Although the original instruments measure many aspects of work with the elderly, it was the purpose of this study to focus only on preference for work in the following four areas:
* Nursing specialty: geriatrie/gerontologie;
* Age groups of patients: aging (45 to 64); aged (65 to 74); old (75 and over);
* Work setting: extended care facility (nursing home);
* Diagnostic group: geriatrics.
On each item the participants' responses were coded strongly prefer (I) to strongly not prefer (5).
The instrument was given to the students to fill out at three times throughout the course: (1) at the beginning of the semester prior to any exposure to either the course content or clinical experiences, (2) at the midpoint of the semester, after completion of the work with the institutionalized elderly and prior to the second part of the course, and (3) at the end of the course after the students completed their work with the well, community-dwelling elderly. Since initial baseline measures of intent occurred on the first day of class, all participants served as their own control (no treatment) subject. Data collection points are referred to as Phase 1 (pre-course experience), Phase 2 (nursing home experience), and Phase 3 (community experience). In addition to filling out the instrument at Phase 1, the participants also were asked to complete a set of demographic questions.
An initial analysis was performed using the students' responses at Phase 1 to describe their pre-course intentions toward work with the elderly. This description is reported in the form of confidence intervals for the six items. In the demographic section of the instrument, the students were asked to indicate if they had prior formal (for pay) work experience with the elderly, and to indicate whether any of their family members had ever cared for an older person within the home setting (informal care-giving). Also included in the initial analysis was a 2 X 2 analysis of variance to see if the students' responses to the six work preference questions are affected by these two questions.
The final analysis was intended to test the main hypothesis that students' intentions toward work with the elderly changed as a result of the course's clinical and didactic experiences. The observation across the phases represented repeated measurements on the students. To account for this inherent dependence between the phases, a mixed analysis of variance model, with students as the random factor and phase as the fixed factor, was run to analyze the work intention responses. Controlling for the variation due to the students in this type of blocking design would produce results equivalent to that from employing a repeated measures analysis of variance model.
The confidence intervals in Table 2 describe the precourse intentions of students toward work with the elderly in four areas: nursing specialty, age groups of patients, work setting, and diagnostic group. With the exception of working with persons characterized as "aging* (45 to 64 years), most of the students were entering the course indicating that they would prefer not to work with the elderly.
ANOVA of the Relationship Between Formal and Informal Work Experiences and P re-Co u r se (Phase 1) Intentions
A 2 x 2 analysis of variance was then run to see if previous work experience and/or family member experience with caring for the elderly affected how the students responded to the six study questions. Results of the analysis (Table 3) show that for all six questions there was no significanee in the main effects of formal or informal care-giving experience with the elderly (p>0.28). Furthermore, the interactions of these two effects were not significant in any of the six categories encompassed by the six study questions (p >0.1). These results indicate that the students* pre-course intentions toward work with the elderly are not affected by whether they have previous exposure working with the elderly on a formal and/or informal basis.
ANOVA of Student Intentions Across Phases
The results of the mixed model analysis of variance found the blocking factor (effect due to the student) to be significant for all six intention questions (p<0.0001). This was to be expected because students were not thought to form a homogeneous group with respect to the six work intention categories. However, after controlling for this variation due to the student, there was no significant difference across the phases in any of the six work intention questions (p>0.2). This indicates that the students did not experience a change in their intentions toward working with the elderly as a result of their clinical practice or any didactic information they received regarding nursing care of older individuals (Table 4).
The design of this study was not set up to account for the possibility of a carry-over effect between the two separate clinical experience situations covered in the course. As a consequence, the Phase 3 measurements might be biased by the Phase 2 measurements. However, it is surprising that there was not even a significant difference between Phase 1 and Phase 2 since clinical experience with the institutionalized elderly was anticipated to result in a significant decrease in the work intention responses.
Generalizability of the findings of this study are limited by the small sample size, and the lack of a longitudinal perspective that could have provided information on intentions after continued educational exposure to older persons in a variety of settings. The unique nature of the curriculum in the baccalaureate program used for this study is another limiting factor since fewer than 12% of university-based nursing programs offer specific, nonintegrated courses in gerontologie nursing (Moses & Lake, 1968). Finally, the participation of one of the principal investigators in both the data collection phase of the research and the clinical and didactic instruction under investigation may have biased some of the students' responses.
Although more than 50% of the students indicated on their final evaluations that their attitudes toward the elderly were becoming more positive as a consequence of this course, the intent to work with this age group remained consistently low. There was no indication that teaching effectiveness was an inhibiting factor since all of the students successfully completed the course and evaluations of instructors were above average, with highest rankings given to those categories related to "enthusiasm about working with the elderly" and "knowledge of age-specific content."
It may be that students in this stage of their professional education find it impossible to speculate about their future career pathways. Since the placement of the course "Nursing Care of the Elderly" occurs early in the junior year, students would not yet have been exposed to other specialties such as pediatrics, obstetrics, and mental health nursing, which may prevent a realistic appraisal of future work intentions. Reassessing intentions at a later point and upon completion of their nursing course work might provide different results.
It is also possible that the sequencing of those clinical experiences involved in this study influenced the findings. Gioiella (1986) and Gunter and Estes (1979) have suggested that students should be exposed to the well elderly first, and then to those in institutions. One encouraging finding of this study was the lack of a significant decline in intentions after the nursing home experience, since it was anticipated, based on the literature, that students' negative intentions would be further biased by offering the nursing home experience first.
Continued research to clarify the ambiguous findings related to the influence of education on future career choices of students is not only indicated, but essential. Reinforcement of factors that foster a desire for work with older persons will benefit not only academicians, but clinicians and administrators as well. Although work with the elderly traditionally has been considered to occur only in extended care facilities, current case loads of aged clients in all health care settings makes most nurses, in reality, gerontologie specialists.
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ANOVA of the Relationship Between Formal and Informal Work Experiences and P re-Co u r se (Phase 1) Intentions
ANOVA of Student Intentions Across Phases