Nurses must be prepared to care for the growing number of older adults, which is expected to increase to 72 million by 2030 (Administration on Aging, 2011). The American Association of Colleges of Nursing (AACN; 2006, 2010) has advocated geriatric competencies in nursing curricula to enhance the care of adults aged 65 years and older. This geriatric content includes recognizing the complexities of acute and chronic comorbidities and facilitating safe transitions of care from community to acute and long-term care. To prepare future nurses to meet this need, innovative teaching strategies, such as case exemplars, focusing on the care of older adults can be integrated into established curricula. The purpose of this article is to describe the development of an older adult case exemplar project in a baccalaureate nursing program and to identify the potential for interprofessional academic partnerships.
Nurses encounter older adult clients in settings such as acute care, home care, ambulatory care, rehabilitation, and long-term care. Therefore, it is vital that nursing education be structured to incorporate more innovative teaching strategies that are designed to enhance caring for older adults.
Geriatric content can be represented by a separate course, or it can be integrated throughout a nursing curriculum. The content in this exemplar was integrated throughout a four-semester program that did not have a stand-alone geriatric course. To promote creative teaching methods, a case exemplar was developed to enhance existing geriatric content in the program. The project included clinical simulation, which incorporated interprofessional content, emphasizing a team approach to geriatric care management. This project was intended to help students synthesize knowledge through innovative laboratory simulation activities and an unfolding case scenario across the 2-year, upper-division nursing program (i.e., junior and senior years). Throughout the four-semester project, first-year students met in the debriefing rooms of the nursing laboratory for instructor-led case scenario group work. Second-year students continued with the case scenario work and completed the simulation using the laboratory to model a hospital environment.
Traditionally, geriatric content was limited to didactic and clinical experiences, which often did not include a specific geriatric course. Historically, only 23% of baccalaureate programs have included a mandatory geriatrics course (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). In 2001, the AACN funded 20 baccalaureate and 10 graduate nursing programs to enhance didactic and clinical geriatric content in their curricula (AACN, 2006). A review of these implementations resulted in the creation of an AACN faculty resource guide, which presented recommendations that nursing programs (a) fully infuse geriatrics into the curriculum, (b) create a stand-alone geriatric course, (c) enhance the curriculum with technology, and (d) support students’ interest in geriatrics. These recommendations have prompted dialogue within schools of nursing to explore optimal ways to deliver this content. Consequently, many programs have revised their curriculum to enhance education about nursing care of older adults through various approaches, including innovative teaching strategies.
For example, the curriculum at Fairfield University School of Nursing was revised to include a separate geriatrics course (Wallace, Lange, & Grossman, 2005). Because this content was previously integrated in other courses within the nursing curriculum, the faculty voiced concern about this change due to fears of the geriatric content becoming addressed only minimally in the rest of the curriculum. They questioned students’ ability to integrate content at more advanced nursing levels without having a strong grasp of the basic tenets of nursing care of older adults, which is taught in beginning nursing courses. Subsequently, they placed the geriatric course early in the curriculum to provide a strong foundation for students progressing through the program (Wallace et al., 2005).
Other institutions have chosen to integrate geriatric content throughout the curriculum (Blais, Mikolaj, Jedlicka, Strayer, & Stanek, 2006). Schools of nursing at both Otterbein College and Florida International University have integrated this content from the sophomore through senior levels. Although not identical, both curricula included this content in all nursing courses, culminating with a capstone course or project related to the care of older adults (Blais et al., 2006).
Some programs have used creative innovative strategies to teach nursing care of older adults and their families (Burbank, Dowling-Castronovo, Crowther, & Capezuti, 2006). Faculty at New York University created a mentoring project that paired students with older adults in the community. This experience fostered student awareness of older adults’ perspectives of the aging process. It also helped students to determine normal age-related changes and their effects on the health and functional ability of community-dwelling adults (Burbank et al., 2006). Tuskegee University created an elective course that explored how older adults maintain productive lifestyles through various holistic health promotion and risk reduction strategies. Also, it examined the effect of cultural diversity on the aging process through a variety of course assignments (Burbank et al., 2006). Unique strategies such as these integrated geriatric content into nursing curricula, while enhancing students’ holistic understanding of older adults.
Clinical simulation in nursing education is a highly effective learning strategy, which can integrate the care of older adults into the curriculum. Sheets and Ganley (2011) introduced geriatric content in a high-fidelity (lifelike) simulation laboratory, using diverse scenarios at multiple faculty-facilitated stations. These simulations provided a safe learning environment without compromising patient safety. Spunt and Covington (2008) also noted the value of student participation in a debriefing process after simulation completion. Although the use of simulations can be incorporated into the curriculum for learning patient care across the age continuum, a simulation focusing on older adult care was developed for the case exemplar project described herein. The simulation was essential for helping students to grasp concepts about the unique characteristics of the older adult population.
The focus of this project was to develop a plan for building a detailed patient case exemplar to be used throughout the didactic and clinical simulation coursework in a baccalaureate nursing program. A detailed patient case exemplar was created to demonstrate geriatric-focused care across the health care continuum. The project included (a) an exemplar description and curriculum plan, (b) a case scenario, (c) a patient chart, and (d) high-fidelity simulations. The exemplar’s theoretical content (i.e., wellness–health promotion, episodic–acute care, chronic disease management, family caregiving, culturally-sensitive care, and contextualization of care to preserve the strengths and capabilities of older adults) emphasized an evidence-based approach. Patient medical records were created for the clinical components of the nursing curriculum. These records included patient demographics, medical orders, laboratory reports, interdisciplinary care providers’ notes, referrals, and medication administration records. The exemplar activities, which culminated in high-fidelity simulation exercises for advanced students, were integrated seamlessly into the project.
The idea to create a case exemplar project was introduced during interdisciplinary strategic planning meetings at the university of one of the authors (L.J.G.). Project development occurred in several stages. Two nurse educators, one of whom is an author of this article (M.A.), created the initial plan for the case exemplar. During the development process, current student competency levels were assessed for cohorts within each of the four semesters. Subsequently, geriatric content was integrated through the incorporation of skills, assessments, and documentation appropriate to the level of knowledge of each cohort. The case exemplar was designed to promote critical thinking activities that empower students to provide optimal holistic care for older adults and their families. For example, the case of the character, Mrs. Gates, an 85-year-old widow, increased in complexity over time.
As the project developed, a work group of six nurse educators refined and expanded the existing case exemplar to fit into the curriculum. The unfolding case scenario and activities were reviewed for appropriateness, reflecting the simple to the complex tenets of adult learning, and then were strengthened to demonstrate problem solving, decision making, and contextual relevance throughout the four-semester program (Gagne, 1970; Knowles, 1988). For example, the character, Mrs. Gates, was first introduced as living at home, which was a good setting to foster health promotion skills. She was later admitted to a hospital and then to a rehabilitation center as her health worsened.
Family-centered care also was integrated into the case scenario when Mrs. Gates needed to live with her adult daughter due to an inability to live alone after being discharged from the rehabilitation center. She was eventually admitted to a long-term care facility and, over time, to an intensive care unit due to complications from a myocardial infarction. This last facet of the case scenario was intended for more advanced students to address serious family needs, including potential end-of-life care. The group created a high-fidelity laboratory simulation exercise, in addition to the Mrs. Gates case scenario. The simulation used a high-fidelity manikin for third-semester nursing students, incorporating another character, Mrs. Strokes, a 76-year-old, who was admitted to an acute care facility with symptoms of a cerebrovascular accident and a history of hypertension, diabetes, and osteoporosis. The simulation included a detailed patient chart, with laboratory results and medication administration records. Students answered questions about the patient’s condition prior to the simulation and then assumed various roles, such as nurse or family member, during the simulation. Those serving as nurses received a status report prior to beginning care for this patient. Nursing care included nasogastric tube insertion, tube feeding, indwelling urinary catheter insertion, and medication administration, including insulin.
Throughout the case exemplar, the nursing care of older adults is contextual, relational, and individualized. For example, the care of Mrs. Gates extends beyond learning skills and tasks. Students assess Mrs. Gates’ abilities, home context, and discharge goals and are prepared to work in an interdisciplinary context with other professionals. This emphasizes a contextual focus informed by nursing knowledge, rather than the more traditional medical model focus.
After the completion of the initial phase of the project, a binder containing the case exemplar and an evaluation tool was sent to 10 external reviewers. To establish content validity, the authors selected external reviewers on the basis of their academic and geriatric clinical expertise. The resulting review team consisted of professionals from medicine (n = 2), nursing (n = 2), occupation therapy (n = 1), physical therapy (n = 1), communication disorders (n = 1), social work (n = 1), respiratory therapy (n = 1), and pharmacy (n = 1). The expert feedback was evaluated and incorporated appropriately into the final product.
Project Pilot Testing
Twelve undergraduate students participated in project-related activities. Content mastery of the case scenario of the Mrs. Gates character was achieved by evaluating student group discussion responses and written responses in scenario activities. One objective of this pilot test was to garner input from students to aid in the development of more formal measurement materials, including rubrics for specific activities.
The simulation pedagogy using the Mrs. Strokes character was effective. She had experienced a cerebrovascular accident and required a nasogastric tube insertion, as well as tube feeding. The simulation strengthened students’ geriatric assessment abilities and empowered them to practice skills in situations that occur infrequently in clinical settings. Although the original simulation plan included role-play involving other disciplines (e.g., physical therapy), the initial phase of testing of the simulation included only nursing students. Future plans to conduct project testing with students outside of nursing were discussed during interdisciplinary strategic planning meetings.
Project testing had a two-fold purpose. First, the faculty evaluated student abilities to conceptualize care of older adults throughout the case exemplar. Second, the faculty shared insightful recommendations, such as creating an additional highfidelity laboratory simulation focusing on end-of-life care for future innovative content.
Accomplishments and Lessons Learned
Creating a project to integrate geriatric content into a nursing curriculum requires considerable time, effort, and support. It is crucial for the faculty involved in curricular projects to have some release time from their designated responsibilities to accomplish such tasks (Iwasiw, Goldenberg, & Andrusyszyn, 2009). In the current project, faculty held open discussions to map geriatric content throughout the curriculum and attended conferences focusing on simulation strategies. In addition, the exemplar was presented to faculty from nursing and other disciplines at geriatric education conferences. Interdisciplinary faculty, including those from nursing, medicine, and social work, discussed how the exemplar project potentially could be used in innovative ways.
The focus of this exemplar project was to incorporate interdisciplinary geriatric content into an existing nursing curriculum. Although interprofessional involvement in the process was planned for future implementation, the pilot phase was limited to the nursing discipline.
The diverse backgrounds of the nurse educator work group were instrumental in creating and implementing the project, using a holistic family-centered approach to care. Educators proficient in curricular design facilitated the integration of new content into the existing curriculum. The levels of expertise of the work group members enhanced creativity, as the character, Mrs. Gates, was positioned strategically in various settings reflective of the challenges facing patients and families.
Feedback from the expert reviewers and students was valuable in confirming the interprofessional content and opportunities for clinical reasoning. Expert reviewers noted the case exemplar incorporated a team approach to care and included critical thinking laboratory activities intended to enhance academic interprofessional partnerships. This strategy has been shown to be beneficial because students view critical thinking based on their discipline’s paradigms for problem solving, and their subsequent decision making is crucial to overall team functioning (Rubenfeld & Scheffer, 2010). Feedback from students identified how the case scenario and the simulation enhanced their learning. For example, they valued the increasing intensity of the scenario, as it helped them to see how the care of an older adult can become complicated, requiring multiple disciplines to use their expertise in promoting health and well-being. They noted that the simulation prepared them to care for older adults in a holistic manner.
The intended outcome of this case exemplar project was to strengthen the andragogical geriatric component of an undergraduate nursing program and to promote interprofessional team integration among disciplines, such as medicine, physical therapy, speech therapy, and social work. Geriatric content in the curriculum was strengthened through the characters of Mrs. Gates and Mrs. Strokes, which allowed students to conceptualize care of patients throughout the care continuum. Future direction to pilot test the exemplar with students from other disciplines was planned for later implementation. Interprofessional education such as this is supported by national standards and core competencies (Interprofessional Education Collaborative Expert Panel, 2011). Moreover, such partnerships can improve patient outcomes through increased collaboration and efficient use of resources (Dufrene, 2012; Ho et al., 2008). Therefore, it is crucial to incorporate innovative curricular ideas, such as this case exemplar, to promote better learning outcomes for nursing students caring for the growing number of older adults.
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