Dr. Lane is Assistant Professor, Faculty of Nursing, and Dr. Hirst is Director, Brenda Strafford Centre for Excellence in Gerontological Nursing and Associate Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Annette M. Lane, PhD, RN, Assistant Professor, Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada T2N 1N4; e-mail: email@example.com.
Within the past several decades, there has been a plethora of reports and research on the attitudes of nursing students toward older adults and the importance of selecting appropriate clinical sites for learning and positively impacting students’ perceptions of gerontological nursing (Haight, Christ, & Dias, 1994; Happell & Brooker, 2001; Sheffler, 1995). Three decades ago, concerns were raised about placing students in nursing homes (Cook & Pieper, 1985; Roberts & Powell, 1978). It was suggested that these placements contributed to students’ ageist beliefs and were poor learning environments due to a lack of appropriate mentorship, and that placing first-year students in nursing homes is unfair to the residents. Perhaps in response to these reports, some undergraduate nursing programs abandoned the use of nursing homes for clinical placements of students. However, since the early reports about the use of nursing homes, a notable shift in the literature and research has occurred with an emphasis on creative strategies and innovative gerontological placements to enhance students’ interest toward caring for older adults.
In the past 15 years, a small number of articles and research studies re-examining the practice of placing undergraduate nursing students in nursing homes has emerged. This literature and research reveals that there is a beginning swing toward again considering nursing homes as viable and worthwhile placement sites for students. What are the reasons for this pendulum swing, and if nursing homes are once again being used for placements, what must happen to enhance the experience for nursing students and nursing home staff and residents?
We present a literature review on the use of nursing homes for students’ clinical placements. We also address the returning shift toward accessing nursing homes for student placements, as well as the particular models or strategies regarding how to maximize learning experiences. Within the literature review, we situate a recent development—The Brenda Strafford Centre for Excellence in Gerontological Nursing—as a partnership between the University of Calgary, Faculty of Nursing and three nursing care facilities in Calgary, Alberta, Canada. We describe this partnership, how the Centre is working to enhance gerontological knowledge and commitment on behalf of undergraduate nursing students, and how the Centre addresses placements within nursing homes. Finally, we offer implications for nurse educators.
Using the search terms nursing homes and student placements, we searched the CINAHL® and Medline® databases. We uncovered 35 articles, including anecdotal reports, literature reviews, and studies, that examine the use of nursing homes for placement of undergraduate nursing students. Of these articles, several were anecdotal testimonials of past experiences in nursing homes (Royds, 2010; Ryan, 2010; White, 2011), two were literature reviews (Kerridge, 2008; O’Connell, Ostaszkiewicz, Sukkar, & Plymat, 2008), 10 were research studies (Abbey et al., 2006; Banning, Hill, & Rawlings, 2006; Berntsen & Bjork, 2010; Chen, Brown, Groves, & Spezia, 2007; Grealish, Bail, & Ranse, 2010; Hartley, Bentz, & Ellis, 1995; Robinson, Abbey, Abbey, Toye, & Barnes, 2009; Rogan & Wyllie, 2003; Schrader, 2009; Wade & Skinner, 2001), and the remaining articles were discussions on various aspects of student placements in nursing homes. Nine articles and research studies focused on models or formalized strategies to enhance the gerontological knowledge of students and their experiences in nursing homes (Banning et al., 2006; Chen, Melcher, Witucki, & McKibben, 2002; Davies, Gell, Tetley, & Aveyard, 2002; Grealish et al., 2010; Kerridge, 2008; O’Connell et al., 2008; Rogan & Wyllie, 2003; Storey & Adams, 1999, 2002).
To explain how the Brenda Strafford Centre for Excellence in Gerontological Nursing fits within current models and strategies for nursing home placement of students, we first provide a summary of the literature review findings and then we discuss models or formalized strategies to enhance student placements. We also discuss the goals of the Centre and how its work compares with current programs or strategies to enhance the experiences of student placements in nursing homes.
Reasons for Reconsideration of Nursing Homes for Student Placements
Several reasons are indicated for the need to reconsider the use of nursing home placements for undergraduate nursing students. First, burgeoning of the older adult population necessitates that nursing students learn to care for this population. Even if students do not specifically choose to work in gerontological nursing after graduation, they will inevitably care for older adults in other areas of nursing at various points in their careers. Second, the dearth of clinical placements has resulted in a search for alternate, yet appropriate, clinical sites. Hence, the option of nursing home placements for students is being revisited (Chen et al., 2002). Third, in some countries, such as Norway, clinical placements within nursing homes are obligatory (Berntsen & Bjork, 2010).
Overall, the literature and research is somewhat positive about clinical placement of students in nursing home environments (Banning et al., 2006; Berntsen & Bjork, 2010), but the enthusiasm is muted by a discussion of the challenges and considerations. Nursing home placements can be positive, provided there is adequate and structured informational and faculty support. Nursing home units are viewed as providing excellent opportunities to practice communication skills, health assessment, and basic nursing care, as well as to become familiar with policies and procedures and to understand how a nursing home is a nurse-led health care environment (Andrew, 2010; Chen et al., 2007; Storey & Adams, 2002). However, despite the acknowledgment that nursing homes can provide viable learning opportunities, there is no consensus on when undergraduate nursing students should be exposed to these units (Wade & Skinner, 2001). Some authors advocate placement for first-year nursing students (Hartley et al., 1995; Rogan & Wyllie, 2003) to facilitate development of basic hands-on nursing skills, whereas others report that senior nursing students are more appropriate (Karam & Nies, 1995; Williams, Nowak, & Scobee, 2006) because their knowledge and skills can be used for development of care protocols.
Within the discussions of the benefits of student placement in nursing homes, there is an acknowledgment of the inherent challenges. First, students are often disappointed and negative about nursing home placements. Although some students report that they learned much within the nursing home placement, they still acknowledge they would choose an acute care environment if given a choice (Banning et al., 2006). Second, nursing homes lack RN-qualified staff to mentor undergraduate nursing students (Abbey et al., 2006; Lumley, Calpin-Davies, & Mitchell, 2000). This can lead to undergraduate nursing students performing the work of nursing aides without the important linkages of practice and theory within the homes. Third, there is also an identified lack of knowledgeable and enthusiastic faculty to work with students in nursing home placements (Chen et al., 2002). When faculty instructors without gerontological knowledge or passion supervise students in nursing homes, not only do they transmit negative messages to the students about working with older adults, but they may fail to make the connections between practice and theory that make the clinical placement meaningful (Schrader, 2009).
Within our review of the literature and research, two major considerations were evident regarding the use of nursing homes for student placement. First, there must be knowledgeable and committed faculty to link theory relevant to gerontological nursing to the actual practice in a nursing home environment (Banning et al., 2006). Not only do these instructors actively make theory–practice connections for the students, through their knowledge and attitudes they model that gerontological nursing is a specialty (Banning et al., 2006) rather than an end-of-career employment choice (Abbey et al., 2006). However, most often it is presumed that these gerontological specialists are hired into faculties because of their expertise rather than recognizing that some faculty acquire these skills after hiring due to program needs. Second, models or formalized strategies are needed to enhance students’ nursing home experiences.
Models or Formalized Strategies to Enhance Students’ Nursing Home Experiences
In the literature, authors advocate for educational models or strategies to enhance the experiences of nursing home placement for students. Although models and formalized strategies from various nursing programs may differ, the aim is to link gerontological education with actual clinical experiences in nursing homes (Rogan & Wyllie, 2003). This educational component may involve a solid orientation to the nursing home (Chen et al., 2002; Robinson et al., 2009), modules offered (within the nursing program) on gerontological content prior to the clinical placement (Rogan & Wyllie, 2003), and specific activities during the placements to ensure praxis (Storey & Adams, 1999, 2002).
Some authors propose the importance of the link–tutor (i.e., faculty lecturers who oversee students in clinical experiences) in the nursing home placement experience for students in the United Kingdom (Davies et al, 2002; Kerridge, 2008). The link–tutor works with students in the nursing home environment and with the nursing home staff and becomes a link between the university and the nursing home (Davies et al., 2002; Kerridge, 2008). Alternatively, a gerontological nurse specialist may provide teaching and modeling for undergraduate students, in addition to providing care for residents within the nursing home (Karam & Nies, 1995).
Another model discussed is the formal partnerships between nursing homes and universities (Chen et al., 2002; Storey & Adams, 1999, 2002). Nursing homes are selected based on their reputation of providing quality resident care. The partnerships are of mutual benefit in that students have learning experiences within the nursing home environment and nursing home staff have learning opportunities, such as study or conference days, education from the faculty and students, and access to university resources (Chen et al., 2002; Davies et al., 2002; Grealish et al., 2010; Kerridge, 2008).
From our literature review, it appears that a key strategy in the placement of students in nursing homes involves the ability of the educator to provide mentoring (Wade & Skinner, 2001) and emotional coaching. This coaching involves helping students work through preconceived ideas about aging and nursing homes (Abbey et al., 2006; Storey & Adams, 1999, 2002) and challenges of working with nursing home staff, as well as coping with death and dying.
The Brenda Strafford Centre for Excellence in Gerontological Nursing
The Brenda Strafford Centre for Excellence in Gerontological Nursing is a model that represents innovative and creative strategies for enhancing gerontological knowledge and commitment among students, as well as enhancing students’ nursing home experiences. The Centre was founded in July 2008 and is a unique partnership between the Faculty of Nursing, University of Calgary, and the Brenda Strafford Foundation. The Brenda Strafford Foundation owns three nursing homes, as well as an assisted living facility/nursing home for older adults in Calgary, Alberta, Canada. The mandate of the Centre is threefold: (a) to promote academic and clinical excellence in gerontological nursing education at both the undergraduate and graduate levels, (b) to attract graduates into leadership positions within long-term care, and (c) to provide ongoing education to nurses in nursing home and assisted living settings. This tripartite mandate is reciprocal in that it is meant to benefit students needing placements, as well as benefiting staff in nursing homes and assisted living facilities. As such, we describe some current strategies of the Brenda Strafford Centre for Excellence in Gerontological Nursing that target both students and staff.
Clinical and Mentorship Experiences for Students
Where and when students are placed within the nursing homes and assisted living facilities are deliberate choices. For example, third-year students in a community rotation may be placed in the assisted living facility of one nursing home. These students work on projects that will benefit the community of older adults. Fourth-year (senior) students may be placed in any of the nursing homes to learn the skills necessary for leadership within long-term care settings.
The timing of the placement is purposeful. For instance, fourth-year students have focused on technical skills within their medical–surgical placements; therefore, they will enter this environment seeking to develop other skills. In choosing a nursing home placement, the student can focus on nursing leadership, regulations and policies, and working with families within the nursing home. They also can focus on complexities of understanding and responding to pathology in older adults, such as when an older adult experiences a delirium superimposed on a preexisting dementia. Our hope is that senior students who are passionate about gerontological nursing might receive the professional grooming they require to step into a leadership role within nursing home or assisted living environments at the beginning of their career rather than at the end.
Not only are senior-year students targeted due to existing knowledge and maturity, but hopefully they have received mentorship throughout their program. A key strategy of the Brenda Strafford Centre for Excellence in Gerontological Nursing involves mentorship of students. Faculty who are interested in and committed to gerontological nursing are paired with students across the 4 years of the undergraduate program who had initially expressed interest in working with older adults. Students can form relationships with faculty members who are passionate about gerontological nursing, can work on projects related to gerontological nursing, and can seek information and advice from their mentors. As a part of mentorship and facilitating professional growth, students may receive some funding from the Centre to attend gerontological conferences and may receive help in constructing poster presentations or writing articles for journals. This mentorship across the years of nursing education may lead to nursing students selecting gerontological nursing as a final practicum, regardless of the type of setting (e.g., nursing home unit, acute care geriatric unit, or community geriatric mental health team).
Clinical Mentorship for Staff in Nursing Homes and Assisted Living Facilities
A number of strategies are in place to address clinical mentorship for staff in clinical settings. First, the Director of the Brenda Strafford Centre for Excellence in Gerontological Nursing is at each site weekly to provide mentorship and problem solving for and with staff. Second, through faculty members at the Faculty of Nursing, University of Calgary, staff receive inservices or all-day workshops on topics germane to practice with older adults. Third, an advanced practice applied gerontological nurses’ research group meets approximately monthly at one of the sites. This group of nurses, drawn from academic and clinical settings, supports the interactions that inform practice, and its members are role models for staff development.
Evaluation of the Model
Evaluation of the Brenda Strafford Centre for Excellence in Gerontological Nursing is currently underway; hence, data are preliminary. However, informal evaluation has revealed an increase in the number of e-mails from undergraduate students raising ethical questions about clients for whom they are caring (e.g., the use of soft restraints), heightened communication with the program clinical placement coordinator regarding appropriate sites for gerontological learning, a greater number of requests from clinical instructors for learning strategies and activities for students, as well as gerontological resources for themselves, and a proliferation of student involvement and enthusiasm in gerontological events. Formal evaluation has indicated a solid gerontological component in the current undergraduate curriculum at the University of Calgary, Faculty of Nursing, as well as resoundingly positive evaluations of an educational day for staff in the two nursing home facilities.
Implications for Nurse Educators
From our experiences, as well as the literature review, we believe there several important implications for nurse educators. These implications address how gerontological nursing is conceptualized and the pedagogy and pragmatics of teaching.
Our experience, as well as the research reviewed in the literature, suggests that gerontological nursing is viewed as a dead-end job, not as a challenging and professionally demanding career. Educators need to be careful about what messages they transmit regarding the specialty of gerontological nursing, irrespective of their personal beliefs. In interviewing 14 nurse educators, Schrader (2009) found that many nurse educators thought that nursing home environments were unpleasant, were not challenging, and offered limited clinical opportunities. Nurse educators admitted that nursing homes triggered personal issues regarding aging. Schrader (2009) suggested that each nursing program have a gerontological nurse specialist who can positively model how gerontological nursing is conceptualized.
We advocate for a nuanced understanding of the challenges in fostering gerontological competence in nursing students. This involves the determination to not look for simple answers to the challenges of attracting students to gerontological nursing. For instance, although there is evidence that increased knowledge and improvement of attitudes toward older adults leads to a willingness to consider gerontological nursing as a career option, this is not a linear equation. Williams et al. (2006) evaluated the effect of placing senior-year students in nursing homes on commitment to geriatric nursing in the future. Although the students in that study indicated their experiences had been generally positive, none indicated they would work in nursing homes after graduation, but a few considered working with older adults in the community. More research must be conducted to unravel the complex relationship among gerontological knowledge, attitudes toward older adults, and commitment to gerontological nursing.
We suggest the need for a carefully constructed plan to foster interest in and commitment toward gerontological nursing. This plan should encompass all years in a baccalaureate program and include not just gerocentric curriculum, but also modeling by faculty members committed to and excited by gerontological nursing and formalized mentorship for nursing students. Mentorship should involve one-on-one relationships with faculty members and students, as well as opportunities to attend lectures, provocative films on aging, and conferences.
As part of this plan, we posit that careful consideration is needed regarding the when of nursing home clinical placement for students. The need for placements alone does not justify placing students in nursing home environments. If nursing programs use nursing home placements in the first year, or any year, careful planning must occur where students receive appropriate curricular support (in terms of theory), and strong faculty leaders are required in the clinical environment who can actively make the connections between theory and practice. These faculty members should be particularly familiar with helping students process emotions associated with the nursing home environment, aging, and death and dying. Faculty can also help students process and constructively manage disappointment when the ideals of theory do not work out in practice. For instance, in the study by Skaalvik, Normann, and Henriksen (2010), senior-year students learned about person-centered care of older adults with Alzheimer disease. The students entered their nursing home clinical placement excited about seeing the person-centered care practice in action and were disappointed when it was not seen among staff, even when they witnessed kindness in the actions of the staff members. It is important to have faculty members who can help students bridge the ideal with reality in a way that does not dampen commitment to gerontological nursing.
Finally, there needs to be a formalized mechanism to evaluate the effectiveness of this plan used to foster gerontological competence and interest in students. Students should be asked to evaluate various components of the plan throughout the 4-year program, as well as at a time point after graduation.
For many reasons, including the aging of the Western World and the challenge in finding appropriate clinical environments for nursing students, the notion of placing students in nursing homes is being revisited. To foster positive clinical placements in nursing homes, as well as to enhance gerontological competence in nursing students, we suggest that nursing programs implement a model or well-constructed plan. The Brenda Strafford Centre for Excellence in Gerontological Nursing is an example of such a model. Although faculty expertise, time, and commitment to such a model is necessary, we believe that this level of knowledge and planning is essential to equipping future nurses to effectively care for our aging population.
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