Journal of Nursing Education

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Baccalaureate Student Gerontological Nursing Experiences: Raising Consciousness Levels and Affecting Attitudes

Sherry D Fox, PhD, RN; Jean E Wold, MN, RN

Abstract

ABSTRACT

The purpose of this study was to evaluate perceived learning and attitude changes of nursing students (n=144) toward care of the elderly population as a result of a senior capstone course in gerontological nursing. Theory content emphasized maximizing individual capabilities of the elderly and quality of Life. Clinical placements occurred in a variety of community and institutional settings, with a wide spectrum of elderly. Student attitudes were assessed using researcher-designed tools for quantitative and qualitative outcome measurements. Significant improvements in student attitudes were found (p<.001). Community-based settings provided significantly more positive experiences (p<.05) compared with institutional care. Qualitative findings revealed students gained positive awareness plus growth in professional abilities. We conclude that a senior capstone course with multi-site, independent, innovative projects can produce positive attitudes and heightened consciousness regarding gerontological nursing. Other nurse educators can benefit from these findings.

Abstract

ABSTRACT

The purpose of this study was to evaluate perceived learning and attitude changes of nursing students (n=144) toward care of the elderly population as a result of a senior capstone course in gerontological nursing. Theory content emphasized maximizing individual capabilities of the elderly and quality of Life. Clinical placements occurred in a variety of community and institutional settings, with a wide spectrum of elderly. Student attitudes were assessed using researcher-designed tools for quantitative and qualitative outcome measurements. Significant improvements in student attitudes were found (p<.001). Community-based settings provided significantly more positive experiences (p<.05) compared with institutional care. Qualitative findings revealed students gained positive awareness plus growth in professional abilities. We conclude that a senior capstone course with multi-site, independent, innovative projects can produce positive attitudes and heightened consciousness regarding gerontological nursing. Other nurse educators can benefit from these findings.

Introduction

The nursing literature is replete with articles reviewing and researching methods of teaching gerontological nursing content to undergraduate students (CoLlins & Brown, 1989; Eddy, 1986; Hanson & Waters, 1991; Hogstel, 1988; Maddox & ??ßtß, 1991; Nelson, 1992; Taft, 1986). Much discussion centers around the need to improve student attitudes toward care of the elderly and to influence career choices to meet the potential health care needs of our burgeoning population of older adults. Topics such as selection of clinical sites, sequencing of experiences in the curriculum and integration of content versus separate courses continue to spark discourse and debate among nurse educators (Brower & Yurchuck, 1993; Dellasega & Curriero, 1991; Earthy, 1993; Gioiella, 1986; Holtzen, Knickerbocker, Pascucci, & Tomajan, 1993; Johnson & Connelly, 1990; Matzo & O'Reilly, 1993; Philipose.Tate, & Jacobs, 1991; Spier, 1992). Additionally, faculty have explored various teaching methods, evaluating effects on student attitudes and knowledge (Brower & Yurchuck, 1993; Greenhill & Baker, 1986; Harrison & Novak, 1988; Langland et al., 1986; Lyles, Larisey, & Morrill, 1988; Spier, 1992; Timms, 1990; Yurchuck & Brower, 1991).

Difficulty with attitude outcome measurements of student learning experiences continues to plague nurse researchers. Commonly used attitude measures are the "Attitudes Toward Old People Scale" or the TuckmanLorge "Attitudes Toward Old People" questionnaire (Chamberland, Rawls, Powell, & Roberts, 1978; Eddy, 1986; Greenhill & Baker, 1986; Gunter, 1971; Hart, Freel, & Crowell, 1976; Langland et al., 1986). The ambiguous results of some studies using these measures suggest that reliability is somewhat limited. Studies often fail to show significant differences between pre- and post-clinical measures. Reports of anecdotal responses of students' attitudes following gerontological experiences are often positive, but quantitative substantiation of attitude changes is not always consistent (Chamberland, Rawls, Powell, & Roberts, 1978; Dellasega & Curriero, 1991; Eddy, 1986). Few studies have used qualitative analysis, although several researchers broaden survey results by including anecdotal data (Nelson, 1992; Robertson & Cummings, 1991).

It is clear that nurse educators must continue to design, implement and evaluate innovative courses and learning experiences that will raise consciousness levels and improve attitudes toward working with the elderly in diverse care settings, as well as increasing interest in gerontological nursing careers. A report on such an effort follows, using a senior capstone clinical approach, evaluated by both quantitative and qualitative measures.

The Gerontology Nursing Project

In the Fall of 1991, the faculty of a baccalaureate nursing program made curricular revisions to shift a portion of gerontological nursing content from fundamentals and public health courses in order to create courses specifically devoted to gerontological nursing at the senior level. Although considerable gerontological content remained integrated in earlier courses, a capstone experience with mature students was envisioned. Thus students could build on previous learning and focus on the complex nature of health care delivery to our aging population as well as the potential changes in nursing practice options the demographics dictate. A major intent of the course was to present a positive, proactive experience in working with elderly clients and to expand appreciation for the many potentials available in gerontological nursing, as opposed to the limitations which may have been perceived by the novice student in earlier courses.

One semester unit (15 hours) was allocated to theory and 1.5 units (67 hours) to clinical experience. The theory was concentrated in a workshop format with all classes taking place during the first 3 weeks of the semester. Content was focused on "ageism," legal/ethical issues, resource allocation, quality of life, physiological and psychological changes, memory deficits, spiritual concerns, love and intimacy issues, multi-faceted assessment, multidisciplinary team approaches and normal versus abnormal aging eventa. Guest presentations by well elders, interdisciplinary team members, consciousness raising films and videos, student group research presentations, and lecture-discussion were used to achieve the learning objectives. A particular focus of these learning activities was an emphasis on the capabilities of senior clients and innovative approaches to maximizing these capabilities to enhance quality of life, rather than just addressing the overt physiological problems and needs.

Armed with current theory, a small library of clinical resources, positive, enthusiastic support and a charge to be innovative within the clinical boundaries, the students created their own clinical projects with faculty guidance. Contracts had previously been established with 35 agencies, consisting of those offering community-based services as well as those providing institutional care. These ran the gamut from "Life-Line" assignees in their homes, senior apartments, board and care faculties, adult day care, home health agencies, hospice and senior nutritional sites, to skilled nursing faculties. Every student had experiences both in institutional care and community settings with direct and indirect faculty supervision. Four faculty shared the individualized clinical supervision each semester. Seminars, journals, papers and self-evaluations were used to determine course grades.

A number of exciting projects evolved including: elder health fairs, a picnic at the mall, memory enhancement education, chair aerobics, wheelchairs to an antique show, field trips to look at wildflowers, reminiscence groups, a duck pond party, and edited video shows taped at agencies, starring clients and their families. In addition, more traditional nursing interventions occurred, including physical, social and psychological assessments of clients (some students also assessed their grandparents), detailed reviews of medication regimens, nutrition education, diabetic teaching, and a multitude of referrals.

Evaluating the Impact on Student Attitudes

The purpose of this study was to evaluate student-perceived learning and attitude changes toward care of the elderly population as a result of a concentrated course in selected gerontological nursing concepts and clinical experiences at the end of the baccalaureate program.

Sample

Seniors in their final semester of Nursing were enrolled in the Gerontology Nursing courses as part of their required curriculum. Participation in the study was voluntary, with informed consent provided. The study was approved by the Human Subjects Committee of California State University, Chico. Social security numbers were used to match pre- and post-test scores. Students were assured that names would not be linked to scores. All students completed both the pre- and post-questionnaires (n=144).

Students were predominantly white (86,2%) (reflecting the homogeneous population of this rural area) and female (94.5%). The average age was 26.5 years with a range of 19 to 48 years of age. Most were generic nursing students (92.6%); 7.4% were licensed vocational nurses returning for their BSN; RN-BSN students were not included in the study.

Method

One hundred forty-four generic baccalaureate nursing students completed the newly developed gerontological nursing courses during the final semester of their nursing program in the 1991-1992 and 1992-1993 academic years. Students were asked to complete pre-test measures on entry to the course. At the conclusion of the clinical (15 weeks later), they completed the post-test measures. Both quantitative and qualitative methods were used to detect the impact of the new theory and clinical courses on students' attitudes about working with the elderly.

Table

TABLE 1Attitudes Toward Working with the Elderly- Comparison of Pre/Post-Test Scores

TABLE 1

Attitudes Toward Working with the Elderly- Comparison of Pre/Post-Test Scores

Instruments

A researcher-devised 6-item pre/post attitude questionnaire was completed by all students (Table 1). These statements were developed by the researchers to assess key attitudes toward working with the elderly, as well as opinions about the elderly as a funding priority in the health care system. These items were selected as we felt they were attitudes the practicum would be most likely to favorably impact. The students indicated level of agreement or disagreement with the statements on a 5-point Likert scale, ranging from strongly agree to strongly disagree.

As the instrument had not previously been used, we examined internal consistency by calculating alpha coefficients for the total scale. The alpha coefficient for the full scale was .5062. Two items, numbers 5 and 6 were omitted to achieve an improved alpha of .6968. In retrospect, it appears these two items were not measuring the same types of attitudes as the first four items, which related more closely to the student's personal nursing role.

Stability was determined by test-retest reliability on a separate class of students (not included in the current sample). Test-retest reliability at a one-month interval was calculated for single items and a total score. Single item reliability ranged from a correlation of .5 (item 1) (not statistically significant) to .9794 (item 6,p<.001). A total score was developed using the modified 4-item scale. Test-retest reliability for the total 4-item score was .8411 (p=.009).

A second instrument was used to evaluate experiences in each agency. This instrument was completed by students in the first year of the study only (n=74). This tool consisted of five statements with a 4-point Likert scale; response choices ranged from strongly agree (4) to strongly disagree (1). A third instrument, a 3-question written response evaluating the courses provided qualitative depth to the quantitative analyses and reflected specific types of learning experiences and resulting attitudes.

Results

Changes in Attitude

The 6-item attitude questionnaire was completed by all students (n=144) (Table 1). Using paired t-tests, four items reflected significant attitude improvements at the conclusion of the clinical experience: perceptions of experience with the elderly as rewarding (t=-4.45;p=.0O0); nursing's role to improve elderly life (t=-3.01;p=.003); confidence in ability to serve the elderly (t=-7.96; p=.000), and perceptions of gerontology nursing as appealing (t=- 4.92; p=.000). The greatest improvement was noted in the students' confidence in their ability to serve the elderly. The mean Likert score improved from 3.98 on the pre-test to 4,5 on the post-test. A scale score was calculated for the above four items. Paired t-test comparisons of pre- and post-scale scores confirmed an overall significant improvement in attitudes at the conclusion of the practicum (t=-8.68; p=.000). These results indicated the practicum experiences had the desired positive effects on students' attitudes toward working with the elderly.

Table

TABLE 2ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Agency provided positive experiences")

TABLE 2

ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Agency provided positive experiences")

Evaluation of Agency Experiences

Agencies were categorized by type (skilled nursing facilities, supervised residential care, hospice, home health, discharge planning, senior nutrition sites, "Lifeline" programs, senior service centers, adult day care centers, etc.). Types of placements were examined for differences in student perceptions regarding positive experiences, opportunity for creativity, adequacy of orientation, availability of staff supervision, and amount of time allocated. Given the number of different agency types, the specific categories were collapsed into two general categories, i.e., those agencies providing institutional care (skilled or supervised residential care), versus those agencies which were community-based (e.g., serving outpatient populations). Each student had experiences in both agency types. Fifty-five evaluations of institutional placements and 67 evaluations of community placements were completed by 74 students in the first two classes only. (Most students evaluated both types of placement, with some missing data.) Data were analyzed using a one-way ANOVA to discern differences between these two types of agency placements. For both types of placements, there was general agreement that orientation was adequate. that creativity was encouraged, and that staff supervision was available, with no significant differences between the agency types. However, the community-based agencies did provide significantly more positive experiences for the students (ANOVA F=6.0684;p=.0152) (Table 2). Similarly, students were much more likely to indicate that too much clinical time was allocated to the institutional care agencies compared with the community-based agencies (ANOVA F=3.9096;p=.0504) (Table 3).

These findings are consistent with other studies, indicating that long-term care settings are not as attractive as community-based settings (Felsen, 1993). In contrast, Greenhill and Baker (1986) found no differences in attitudes of students working with non-institutionalized elderly compared with students assigned only to nursing homes. Langland et al. (1986) maintain that positive attitudes can be developed in institutional as well as community-based settings. Based on our findings, we would recommend a mix of the two types of experiences for all students.

Qualitative Responses

The quantitative data indicated there were some attitudinal changes. The qualitative data allowed us to explore more fully what those changes were. Three openended questions were asked:

1. Describe two of the most important things you have learned in working with the elderly this semester.

2. What changes would you make in the health care system to improve care or services for the elderly population?

3. Has the experience in (this course) contributed to your development as a professional nurse? If so, how?

One hundred forty-two responses were analyzed. Responses to the three open-ended questions yielded extensive, thoughtful answers, well beyond single words or single sentences. These responses indicated that the students had definite and well-articulated thoughts about these areas of evaluation. Responses for each question were analyzed individually. Written statements from the first 74 subjects were listed and coded according to emerging categories, using open coding techniques described by Strauss and Corbin (1990). Major themes were identified. The themes and coding schemes were cross-validated by the second researcher after the initial coding was complete. Following agreement on the responses from the first year, the responses of students from the second year of the study were analyzed according to the previously identified themes and codes, as well as examined for new codes and themes. No new categories emerged; responses were quite similar across the two years.

Table

TABLE 3ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Too much time was allocated")

TABLE 3

ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Too much time was allocated")

Areas of Learning

The first question asked students to describe the two most important things they had learned in working with the elderly during the semester. The first group of 74 respondents yielded 323 discrete statements about what they felt they had learned. Students elaborated well beyond listing only two items. The most common responses related to increased awareness rather than knowledge of specific facts. Students shared shifts in their own attitudes or consciousness levels, based on their experiences. They described being more conscious of such things as the elders' need for respect, for listening, for autonomy, for social activity, and for patience. Additionally, students realized the elders' potential and capability for independence, community involvement and continued growth and learning. One hundred thirtyeight of the 142 respondents indicated a growth of awareness or knowledge about one or more significant aspects of the elderh/s Uves, needs, capabilities, or changes which occur with aging.

Two key themes became apparent- an increased appreciation for the commonalities between the young and old of this society (labeled intergenerational conunonaUties), and the recognition of the ability of the elderly to actually contribute to society (labeled intergenerational sharing).

Intergenerational Commonalities

Thirty-seven of the 142 respondents commented on their realization of how much the young have in common with the old, revealing a strong growth of identification and empathy for the elderly (see sample responses in Table 4). For example, one student commented:

How unique each person is, and how much they are just like me, only older! They've felt the same feelings, gone through the same things, and were young once just like me. So often we look at them and see how they are now and don't see them as the whole person that includes their past.

Another commented, "They enjoy life just as much as we do. They may have wrinkled bodies, but have young, loving hearts."

Intergenerational Sharing

Forty-two students expressed their newly found appreciation for the contributions made to them by the elderly in their interactions, indicating the value of intergenerational sharing (see sample responses in Table 5). Representative comments include: "I. ..learned more about the elderh/s generation, and what their lives were actually like. This information passing is essential for younger generations to appreciate and learn about the past" and "I've learned that they can educate me with their life experiences. This is something that can't be found in any book." It was clear that the students learned from the elderly, revealing mutually rewarding interactions.

Perceptions of Health Care System Changes Needed for the Elderly

In response to the second question regarding changes needed in the health care system to meet the needs of the elderly, it was evident that the students formed clear ideas of what is needed to improve health care for the elderly, revealing heightened consciousness of the elders' health care dilemmas. An overriding theme in response to question two was the need to increase the resources for health care services, in the forms of Medicare benefits, universal coverage, and funds targeted to provide specific types of services or improved access. Students were concerned with access to care, including the need for transportation and access for the handicapped elderly.

Students gained an obvious respect for home care, fam-\ ily care, board and care, along with the supportive value of home health and adult day care services. Students asserted that the elderly can have a better quality of life in more home-Like settings, and that most are capable of functioning in such settings with a little assistance. For example, one student commented:

I would push for more funding to open care homes that house between 8-12 residents. I feel this is a more humane way to deal with those who are unable to live alone anymore, and I also feel they keep a higher level of functioning in these settings.

However, recognizing the existence and need for skilled nursing facilities, students indicated that much needed to be done to improve this type of service, from increasing the salary, staffing, education and recruitment to achieve a more caring staff, to improving the activities and home-like qualities of skilled nursing facilities. Many applied the positive experience in this course to potential approaches to educating other health care workers, for example,

[I would] change health care workers' negative attitudes towards the elderly, poesibly by requiring that they spend some time working with the healthy elderly population to erase the misconception that all elderly are ill and debilitated.

Students' suggestions for change ranged from a focus on individual political action to broader, system-wide changes, which included educating families, health care workers, and the public to better understand and meet the needs of the elderly. Only one student seemed stymied by the enormity of this question; all other students felt up to the task of making a prescription for action to improve the health care of the elderly.

Professional Development

Responses to the final question may be most indica

tive of the long-term professional impact we hoped these urses might have for the students. All but nine of the espondents indicated the courses had an impact on their profes8ional development. Responses regarding professional development could be categorized into three domains- a perceived increase in factual knowledge, a change in awareness or values, and actual changes in the student's professional self-concept, demeanor, or approach. This last category was labeled "transformative changes." Responses in this category revealed a greater sense of competence, confidence, better ability to communicate, as well as transformations in ability to be patient, compassionate and respectful (see sample responses in Table 6). The students indicated more than just an awareness of the need for these qualities, they indicated they were now capable of bringing those qualities forth. For example:

I have a much better awareness of the elderly and am much more effective in communicating with them. I am more sensitive to their issues now and I will bring this with me dturing my career. It has also given me a new option for my career that I never thought about before!

Table

TABLE 4Sample Responses: Intergenerational Commonalities

TABLE 4

Sample Responses: Intergenerational Commonalities

I have a more complete understanding of the elderly clients. I have improved my interaction skills, teaching skills and knowledge of resources available...I know how to communicate and understand them clearly. Their value has been reestablished in my life.

Discussion

Both the quantitative and qualitative analyses were consistent in estabüshing the positive effects of the capstone gerontology courses. By using both techniques of analysis, it seems certain that meaningful positive attitude changes occurred among the senior nursing students. Only nine students out of 144 expressed limited learning from the experience. Most noteworthy, four reported a reconsideration of career choice to a gerontological field although nothing in the evaluation solicited that information. Earthy (1993, pp. 11-12) speculated that four factors would influence students' decisions to work in gerontological nursing: "genuine interest in older people, a solid gerontological nursing knowledge base, good role models.. .and more exposure to the elderly in a variety of settings..." Several of our students indicated a newly found interest in working with the elderly based on their experiences in the gerontology capstone courses. Exposure to the elderly in a variety of settings contributed to the development of this interest, even though positive role models were not available in every setting. It is possible that the independence and creativity encouraged, along with their professional maturity, helped these senior students transcend the lack of role models.

Students in this program have a first semester fundamentals experience in skilled nursing facilities. They also have experienced the usual large contingent of elderly patients in most clinical settings. These previous learning experiences provided a strong foundation for self-directed nursing activities in a multitude of settings. Attitudes were somewhat positive on most categories on the pretests, indicating that earlier experiences were not all negative, but there was clearly room for a significant level of improvement, as evidenced by the positive results in this study, Our findings demonstrate the positive impact of a senior level course in gerontological nursing, using a combination of institutional and community-based settings for each student. From this experience we conclude that community-based agencies provided the most positive experiences. We recommend that all students have both types of agency experience to develop awareness of both the well and the ill elders' needs and potentials. Although we agree with the benefit of early introduction of gerontological concepts (proposed by Gunter, 1971), we also support the use of an integrating, capstone experience with the advanced student.

Table

TABLE 5Sample Responses: lntargeneratlonal Sharing

TABLE 5

Sample Responses: lntargeneratlonal Sharing

Limitations

Although we affirmed the value of the approaches used in our curriculum for teaching gerontological nursing, a number of factors may limit generalizability. A variety of faculty were involved with the students, and faculty approaches may have influenced student responses. We have not controlled for this factor. There was a diversity of agencies and staff, so each student had a unique experience. Clearly, the community-based agencies had much more positive influence than the skilled nursing facilities, but this might vary by institution. We did not collect data on prior work or family experience with the elderly. Several students noted that the impact of their prior experience with work or family members might set them apart from the other students. Given knowledge of the exploratory nature of the project, students may have been attempting to please the faculty with their positive responses, given our concern and interest in the success of the new clinical. However, studente are usually not so solicitous of faculty. They felt free to complain of problems during the semester, such as perceived inconsistencies related to difficulty of assignments and grading criteria. By the second year, there was no longer a feeling of "newness" to the courses, so the Hawthorne effect was presumably less active for the second half of students.

Table

TABLE 6Sample Responses: Transformative Changes

TABLE 6

Sample Responses: Transformative Changes

The quantitative analysis was limited due to the use of a small (4-item) researcher developed tool to measure attitude changes. Development of this tool served as an expethent measure, given a lack of other well-established and reliable attitude scales relevant to our nursing course objectives. Additional research is needed to farther develop reliable instruments to measure attitude changes in nursing students working with elderly clients. Until such measures are developed, in-depth qualitative analyses may be the best way to evaluate such attitude changes.

Conclusions

We conclude that the opportunity to create projects and activities in diverse settings had a positive effect on attitude outcomes. Students reported great satisfaction with their innovative efforts and the responses of the elderly clients with whom they worked. Many students expressed very profound insights about the elderly, which should apply in any caring situation. They reported increasing sensitivity and holistic assessment capabilities. It is exciting to the project directors to note that the course activities meet many of the gerontological nursing competency statements developed for baccalaureate graduates and endorsed by the National League for Nursing (1992) in their report, Gerontology in the Nursing Curriculum.

Robertson and Cummings (1991) found in a survey of 1,200 long-term care nurses that having a geriatrics clinical rotation in nursing school was one of the highest ranked factors attracting them to long-term care. Our study lends support to this finding, in that several students did express a change in career intentions, based on the course. Thus, it seems important for nursing schools that desire to prepare students for gerontologie nursing to specifically address this population in the curriculum with clinical experiences that reflect the multitude of career options available.

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TABLE 1

Attitudes Toward Working with the Elderly- Comparison of Pre/Post-Test Scores

TABLE 2

ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Agency provided positive experiences")

TABLE 3

ANOVA for Comparison of Types of Agencies (Institutional vs. Community*) ("Too much time was allocated")

TABLE 4

Sample Responses: Intergenerational Commonalities

TABLE 5

Sample Responses: lntargeneratlonal Sharing

TABLE 6

Sample Responses: Transformative Changes

10.3928/0148-4834-19961101-05

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