Dr. Ironside is Associate Professor and Director, Center for Research in Nursing Education, Indiana University School of Nursing, Indianapolis, Indiana; Dr. Tagliareni is Professor and Independence Foundation Chair in Nursing, Dr. McLaughlin is Professor of Nursing, Dr. Mengel is the Head of the Department of Nursing, Community College of Philadelphia, and Dr. King is Senior Program Officer and Director of Research and Evaluation, Independence Foundation of Philadelphia, Philadelphia, Pennsylvania.
This study was funded by The John A. Hartford Foundation and the Independence Foundation of Philadelphia.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Pamela M. Ironside, PhD, RN, FAAN, ANEF, Associate Professor and Director, Center for Research in Nursing Education, Indiana University School of Nursing, 1111 Middle Drive, NU 478, Indianapolis, IN 46202; e-mail: firstname.lastname@example.org.
According to U.S. Census Bureau projections, the population of adults ages 65 and older will more than double between 2000 and 2030, growing from 35 million to more than 70 million (He, Sengupta, Velkoff, & DeBarros, 2005). Much of this growth is attributed to the baby boom generation, which will reach age 65 between 2010 and 2030 (He et al., 2005). Those ages 85 and older, the oldest old, who require the most health care, are the most rapidly growing older adult age group. In 2000, the oldest old comprised 5% of all Americans and 12% of the 65 and older population; they are projected to comprise 24% of the 65 and older population by 2050 (He et al., 2005).
Because adults ages 65 and older in the United States and throughout the world account for an increasing proportion of the population, there is widespread acknowledgement that they have become the “core business” of health care (Mezey, 2004). Approximately 82% of older adults have at least one chronic disease that requires ongoing care and management, with hypertension, arthritis, and heart disease being the most common (Medicare Payment Advisory Commission, 2006). These chronic conditions influence older adults’ quality of life and are major contributors to a decline in functioning; in fact, they have become the primary reason older adults seek access to the health care system (Hing, Cherry, & Woodwell, 2006).
When older adults with chronic conditions enter the health care system for an acute illness, they require complicated care not only to address the acute problem, but also to stabilize the chronic health problems. Data from the Bureau of Labor Statistics confirm that the older adult populations will demand more services from nurses and other health care providers (Figueroa & Woods, 2007). The increased number of older adults and advances in technology (which permit treating and diagnosing a greater number of medical problems) will drive this growth, leading to the need for more comprehensive nursing care. A high level of attention must be paid to the education of nurses, as well as all health care professionals, to meet the demand for more expansive and comprehensive services for older adults. However, the majority of nurses have little, if any, background in geriatric nursing as a specialty (Mion, 2003). Furthermore, nurses generally receive little or no preparation in caring for individuals with multiple chronic problems in the context of the current acute, episodic health care system (Institute of Medicine [IOM], 2008).
In keeping with long-term trends, fully 60% of all new graduates eligible to enter the nursing workforce in 2006 were prepared in 2-year associate degree (AD) programs (National League for Nursing, 2008). Although an increasing number of RNs eventually receive baccalaureate and master’s degrees, as many as 42% of RNs, the largest subgroup currently practicing, received their initial preparation for nursing in an AD program (Health Resources and Services Administration, 2004). Therefore, ensuring nursing competency in caring for older adults across multiple health settings for new graduates of AD nursing programs is imperative (IOM, 2008).
The goal of the project, Fostering Geriatrics in Associate Degree Nursing Education, is to broaden The John A. Hartford Foundation’s geriatric initiatives in nursing education to enhance how students in AD nursing programs are prepared to care for older adults. This article focuses on findings from a national survey of AD programs related to curricula, instructional resources, and clinical experiences.
The survey instrument was developed by the study team, using and adapting many items from the survey conducted by Berman et al. (2005), as well as items that reflected the insights obtained from focus groups with AD nursing faculty. The items were designed to provide a comprehensive look at classroom and clinical experiences in AD programs across the United States.
Survey items were organized into five sections composed of both multiple choice and open-ended questions. In section 1 (2 items), respondents were asked to identify their role in the program and to provide contact information. Section 2 (7 items) focused on curricular issues such as how the curriculum was designed and where care of the older adult was taught in the program. Section 3 (4 items) queried specifically about clinical experiences, including clinical sites used and placement of clinical experiences. Section 4 (3 items) focused on the faculty’s efforts to enhance geriatric content, the challenges to and factors enabling enhancement, and current use of instructional resources. Section 5 (8 items) asked respondents to describe the faculty at their school in terms of number, employment status (full-time versus part-time), and expertise in geriatrics. The estimated survey completion time was 20 minutes.
The survey underwent extensive review and multiple revisions prior to its distribution to associate degree programs nationally. First, a panel of nationally recognized experts in geriatric nursing, from both service and academic settings, provided consultation on the design and face validity of the survey instrument. Second, the instrument was pilot tested by representatives of 2 schools who provided feedback to the study team on the clarity of the items, the scope of the survey, and the completion time required. The study team used these comments to further refine the survey. After the survey was loaded on the American Association of Community Colleges (AACC) Web site in its online format, project staff pretested it for ease of use, formatting issues, and skip patterns.
Five AD nursing programs were visited by study team members for in-depth discussions with administrators, faculty, and students regarding geriatric content and experiences. Schools were selected based on a history of excellence in teaching and leadership, representation from urban and rural schools, and geographic diversity. On the basis of these criteria, schools in Florida, South Dakota, Indiana, Massachusetts, and California were chosen for participation in this study. Meetings with these participants were nonstructured but typically included discussions of questions such as:
- What kinds of clinical experiences involving older adults do students have in the program? How do faculty describe teaching in acute care settings?
- How are clinical assignments made?
- How do faculty approach teaching about older adults? What strategies do they use? What resources do they use? What resources are needed?
Study team members kept field notes of these meetings. When meetings included groups of teachers or students, they were audiorecorded with the consent of all participants for later review by the team.
Project team members also conducted focus groups with practicing nurses from Nurses Improving Care for Health System Elders (NICHE) hospitals and recent graduates of AD programs. Focus groups with NICHE nurses gathered data about their experiences working with new graduates caring for older adults, and their opinions about how prelicensure nursing education programs could better prepare new graduates to care for older adults. Focus groups with recent graduates explored the challenges they experienced as new nurses caring for older adults and the ways their program could have better prepared them to provide this care. Team members kept field notes during focus groups or audiorecorded them with the participants’ consent.
Institutional review board approval was obtained for the study. For the survey, the population of AD programs and director contact information were identified by the AACC. The project administrator sent an e-mail message to all schools in the population describing the study and informing them of the date the survey would be available for online completion. When the survey was posted online, the project administrator sent another e-mail message describing the intent of the survey and requesting that the URL for the survey be forwarded to the person in the nursing program most familiar with when and how geriatric content and experiences occurred in the program. Potential respondents were assured that no information about the school or the respondent would be linked to the survey results and that the team would only use specific information about the school or respondent to describe the population and to send reminders to schools failing to complete the survey. Response to the survey served as consent. The URL for the survey remained open for 6 months, and a series of three e-mail reminders was sent to those schools that had not yet completed the survey.
Student assistants followed up on all nondeliverable e-mails and the team made corrections as needed. Eight hundred fifty-one AD programs were eligible for survey participation. By the survey end date, 531 of the 851 AD schools of nursing had responded, yielding a survey response rate of 62.4%. This response rate is acceptable for a Web-based survey, but may be biased toward respondents who have an interest in teaching geriatrics in AD nursing programs (Fowler, 2009). Respondents represented 47 states and the District of Columbia.
Survey data were analyzed using descriptive statistics. Responses to open-ended items were analyzed using content analysis. Field notes and transcripts of recorded meetings from site visits and focus groups were categorized into general themes using a qualitative data analysis software program, MAXQDA.
Findings revealed a near even split in the curricular structure used in responding schools, with 48% reporting an integrated curriculum and 47% reporting a curriculum organized by individual specialty courses. Five percent reported a combination of integration and specialty courses.
The majority of respondents (80%) indicated that geriatric nursing content and experiences were integrated in nursing courses throughout the curriculum, with an additional 15% reporting a combination of stand-alone courses and integration. These respondents were then asked to estimate the amount of geriatric content in specific courses. Figures 1 and 2 show that care of older adults most commonly comprised 10% to 25% of the content taught in each major course. In courses that typically included classroom and clinical instruction (Figure 1), the greatest concentration of geriatric content occurred in adult health, fundamentals, and mental health courses, wherein 35%, 33%, and 17% of respondents, respectively, indicated that more than 25% of these courses was devoted to geriatrics. Fundamentals was the most commonly cited course, with more than 50% of the content devoted to geriatrics.
Figure 1. Percentage of Clinical Course (N = 531) Content Devoted to Geriatric Nursing Concepts.
Figure 2. Percentage of Skill Course Content (N = 531) Devoted to Geriatric Nursing Concepts.
In health assessment, pharmacology, and ethics/legal courses (Figure 2), a similar trend appeared. Rarely did care of the older adult comprise more than 50% of the content. In fact, most schools reported that the geriatric content comprised 10% to 25% of the content across courses.
Stand-Alone Specialty Courses
Five percent of respondents indicated geriatric content and experiences were provided to students via stand-alone specialty courses only, although an additional 15% indicated a combination of stand-alone and integrated courses. For the 5% of respondents teaching in schools with a stand-alone course in geriatric nursing and the 15% reporting a combination of a stand-alone course and integration, 53% reported the course occurred in the first year of the AD program, whereas 47% indicated that geriatric nursing content was taught in the second year of the program.
Instructional Resources Used by Faculty to Teach Geriatrics
As the Table shows, the majority of AD nursing faculty reported using case studies, NCLEX review questions, CD and/or DVD resources, Web sites and online materials, study guides, and simulation activities to teach care of the older adult. However, it is noteworthy that, with the possible exception of simulation activities, the strategies identified are relatively low tech and may not capitalize on the technological expertise of most students. Very small numbers of faculty created opportunities to utilize online educator discussion forums and resources requiring more sustained technological support. Similarly, streaming videos and handheld technologies (e.g., PDAs) were rarely used. Seldom did faculty report taking advantage of downloadable presentations or demonstrations.
Table: Resources Used in Associate Degree Nursing Programs
Many of the faculty interviewed during site visits reiterated these findings, one observing that students “are more adept at using net-based information searches than a lot of us [faculty] are.” In addition, faculty acknowledged that resources such as assessment tools for use with older adults “are out there,” but they rarely explained how these resources were integrated into their courses. During a focus group, two recent AD graduates identified their major resources for questions about caring for older adults: experienced nurses on the floor because “they’ve seen it and done it,” and their PDAs. One graduate stated her PDA is:
the most helpful tool I can have with me, especially if I don’t have another nurse on the floor I can ask.… If the doctor says something like “This patient has so and so” and I don’t know what it is, I can look it up.
Although both graduate nurses noted there were reference books on the units where they worked, they rarely used them because the PDA had much more easily accessible information. Students also emphasized the importance of having information available at any time. This availability allowed the pooling of resources among students, as well as use of the most current information and resources when teaching older adults. One of the graduates said:
If you look at [accessing resources about caring for older adults], I think the Web is probably…easier [to] access because if you do it that way…you could access it maybe at a remote location. You could have it at your home, you could do it several places… as opposed to [having] to make sure [the patients] have a DVD [player] and [that you] brought the DVD with you.… A lot of places now do have Web access…and you can…actually pull [information] up [wherever you are] or even if you’re here at school and you say [to a peer], “I saw this on there, let me show you.” And you can pull it back up and show someone else, “here it is! You see what I’m looking at there? Go on that website, look at this! See what they have on there. What do you think of that?”
Although students voiced a familiarity with using Web-based resources, and 93% of survey respondents indicated using specific Web sites or other online materials, faculty interviewed during site visits commonly identified the need for more “ready-to-use” strategies and materials that could be easily obtained and used in existing courses. One faculty member identified the need for “a unit or some methodology of teaching that does not just do the content and facts, but [also] talks about how you integrate [geriatrics] in your curriculum [with] suggested learning activities.” Other faculty members talked about wanting resources for student use that showed the progression of particular conditions from middle to old age so that students could become more adept at identifying and addressing these changes.
The survey also queried faculty about their familiarity with and use of specific aging or geriatric nursing resource Web sites, including the John A. Hartford Foundation Institute for Geriatric Nursing; the American Journal of Nursing series: “How to Try This;” the American Association of Colleges of Nursing (AACN) Web site; and Web sites of aging organizations such as the AARP. As Figure 3 shows, the online resources that were the best known and used by respondents were Web sites of aging organizations. Nearly 60% of survey respondents were unfamiliar with newer geriatric resources, including those available from the John A. Hartford Foundation, the American Journal of Nursing series known as “A New Look at the Old,” and the AACN Web site with baccalaureate competencies and curricular guidelines for geriatric nursing. Although slightly more than 25% were familiar with these resources, they rarely used them. Only 15% used the Hartford Institute for Geriatric Nursing resources for information, whereas nearly 40% of respondents reported regularly using aging organization Web sites.
Figure 3. Familiarity and Use of Specific Online Resources.
Clinical Experiences in Associate Degree Curricula
The vast majority of AD programs responding (81%) used nursing homes, or long-term care settings, for students’ clinical experiences with older adults. Of those schools, 71% provided this experience in the first year, 12% in the second year, and 17% in both the first and second years. Three percent of the respondents reported using only long-term care or nursing home settings. Of note, during focus groups with nurses from NICHE hospitals, participants shared the belief that students’ experiences in nursing homes (often the first or among the first clinical experiences students have) gave them a lasting negative impression of caring for older adults. Some participants suggested early experiences for students in settings where they could interact with older adults living more independently as a way to foster positive attitudes toward caring for older adults (Brown, Nolan, Davies, Nolan, & Keady, 2008).
Eighty-three percent of respondents indicated that hospitals were used as clinical settings in which students learned to provide care to older adults. Of note, during site visits, when faculty were asked what factors they considered when assigning patients to students, most faculty cited the disease process or the skills students would be able to perform in the provision of care (frequently, technical skills related to medication or fluid administration, or the use of particular equipment). Rarely was the patient’s age a prominent consideration in planning clinical experiences.
Other Clinical Sites
Respondents also reported using a variety of other clinical sites that provided students with opportunities to learn about caring for older adults. More than 60% of respondents reported using mental health facilities, whereas less than 50% reported using home health/care management settings, rehabilitation centers, and ambulatory care. Less frequently used sites were those in the community, for example, seniors’ independent living facilities (17%), residential housing (8%), churches (5%), and other settings (8%) such as senior citizen centers, community centers, private homes, and physician offices.
Faculty interviewed during site visits noted how concerns about the lack of excellent RN role models in long-term care and the inadvertent emphasis on deficits, dependence, and loss rather than on strengths, capabilities, and assets, often prompted the use of other clinical sites. Indeed, both faculty and student groups were most animated and excited when relating clinical experiences with older adults in community or nonacute settings. For example, at one school, the chairperson reported the following experience she had with students in an assisted living facility:
[The students] were just blown away by how much information these [older adults] wanted and were desperate for, [including information] on how to empower themselves to stay healthier. And the students said, “And we knew! We knew what to do and we could help them!” And it was so gratifying [for the students], and somehow the patient teaching part of it, with a positive spin I think, is another really important [piece].
This perspective was also shared by the students at this school, who were not only enthusiastic about their experiences with older adults in this setting, but also shared ideas for further enhancing this experience (e.g., students suggested that at the end of the semester, the students leaving the setting give a “report” to the students entering the setting “so we don’t lose ground” or so that the older adults can “keep learning and making improvements in their health”).
These findings show that although there is a near even split in the structure of their curricula (integrated content versus stand-alone specialty courses), most AD schools integrate geriatric content and experiences in their programs. Rarely is geriatric content more than 25% of these courses, with the highest percentage of geriatric content occurring in courses focused on adult health, fundamentals, and mental health. These findings were consistent with an earlier survey about baccalaureate curricula conducted by Berman et al. (2005), which reported that 92% of baccalaureate programs integrated geriatrics into one or more courses, with the most geriatric content being presented in medical-surgical nursing (adult health) and fundamentals courses. Clearly, the need to examine the amount of content and number of clinical experiences necessary to prepare AD students to care effectively for the growing population of older adults is critical, regardless of the overall structure of the curriculum. In addition, standards for content and experiences related to caring for older adults in AD programs are sorely needed to guide the enhancement of geriatrics in AD programs.
These findings also suggest that faculty development is needed to support faculty as they learn and creatively use existing resources and newer technologies to support teaching and learning geriatrics. Newer technologies can further assist faculties to teach the progression of various conditions or the subtle changes that students must learn to recognize in caring for the older adult but that fail to be captured in static pictures or textbooks. In addition, making resources readily available to students by new and emerging technology in both classroom and clinical settings would further enhance their learning to care for older adults.
Clinical education is a vital aspect of any nursing program and the nature of clinical experiences shapes students’ knowledge, skills, and attitudes. This study found that most AD nursing schools used nursing homes as a clinical site for teaching older adult care, most frequently in the first year of the program. Williams, Nowak, and Scobee (2006) noted that early experiences (i.e., those occurring in the first year of the program) tend to be so focused on personal care and basic assessment that many students fail to appreciate the complexities of providing care to older adults.
In this study, very few schools reported using nursing homes in both years of the program, thereby providing students with opportunities to observe changes in this geriatric population over time. Even fewer schools reported using nursing homes for more experienced students—students who have developed their abilities to conduct more comprehensive assessments and can address increasingly complex client situations. It is crucial that faculty create innovative clinical models for experiences in nursing homes that promote a positive view of the challenges and rewards of caring for older adults, the advanced knowledge and skill base required for this care, and the changes in this care that occur over time. Clearly, nursing homes are not the only settings in which this learning can occur, but important advances may be obtained by reexamining how, when, and in what ways these settings are used.
Hospitals are commonly used for geriatric nursing clinical education in AD programs. This finding was not surprising because 50% of the patients in acute and ambulatory care are older adults (He et al., 2005). Indeed, it would be difficult to provide clinical experiences in a hospital in which students were not involved in caring for older adults. However, faculty’s predominant focus on disease states and the skills students could perform as the basis for assigning patients to students during clinical experiences suggests that the opportunity for students to recognize and explore the intricacies of caring for older adults may not be fully realized in these sites. In other words, significant enhancements in students’ clinical experiences in caring for older adults may be readily achievable by merely changing the focus of clinical experiences from specific disease states or the acquisition of particular skills to a focus on older adult care (care that will necessarily include a diverse array of disease states and skills).
In addition, the predominant use of hospitals for clinical experiences does not expose students to older adults living independently or take advantage of the diverse settings in which students can learn to provide care to older adults. Such experiences are needed to augment students’ knowledge and skills required to care for the growing population of older adults. The possibilities for substantively enhancing geriatric clinical experiences through the development of experiences that expose students to a positive view of older adults may be greatest with well older adults (i.e., many of whom have multiple health concerns but are still considered well) living independently.
Findings from this study identified several key areas that can foster geriatric competence in AD nursing graduates, the largest segment of new nurses in the United States. First, the need for standards for teaching geriatrics in AD programs is imperative to guide curricular decision making and the design of clinical experiences. Second, faculty development is needed to help faculty learn and creatively use existing resources and newer technologies that can support students at the point of care (as well as in classrooms) by providing them with the latest information related to geriatrics. Third, innovative clinical models are sorely needed that emphasize the complexities of caring for older adults and that occur in nonacute, community-based sites wherein students encounter older adults living independently.
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Resources Used in Associate Degree Nursing Programs
|NCLEX review questions||95|
|CD or DVDs||95|
|Specific Web sites or other online materials||93|
|Bibliographies of topic-specific resources||50|
|Online educator discussion forums||28|
|Resources housed on handheld technology devices||20|
|Downloadable presentations or demonstrations||8|