The World Health Organization (WHO) reports that the global population of people older than 60 years is expected to double by 2050 to 2 billion, of which 434 million will be aged 80 years or more. This means that one in five people will be at least aged 60 years and will outnumber children younger than 5 years (WHO, 2015). As people age, their needs change and the challenges to their health increase as they may live with chronic conditions that can impair their quality of life (Cline, 2015). If older adults are not given the support necessary to be able to manage these conditions, their quality of life is further impaired. This situation is complicated, as many nursing students encounter negative attitudes toward older adults on clinical placements and express a preference to not provide care for this patient population (Eaton & Donaldson, 2016).
It is important that nursing education provides an understanding of how to deliver quality nursing care to older adults in all clinical settings (Baumbusch, Dahlke, & Phinney, 2012; Clendon, 2011). This article reports on an innovative learning strategy developed from Brendan McCormack's ideas of person-centered care as they are explained through the principles of emancipatory practice development. This theoretical approach has been adapted to the educational environment and asks the students to reflect on their attitudes toward older adults and consider that these attitudes affect the care. To encourage attitude change, the students were required to speak with older adults and to reflect on these conversations to consider how they developed person-centered care plans (Buckley, McCormack, & Ryan, 2018).
Nursing students often initially encounter older adults when they have been admitted to the acute care setting and their care needs are at peak level, and the students experience difficulties communicating with older adults (de Almeida Tavares, da Silva, Sá-Couto, Boltz, & Capezuti, 2015). This can produce care that does not consider all aspects of the older adult's life and is ritualistic and mechanized (Berendonk & Caine, 2017; McCormack, Karlsson, Dewing, & Lerdal, 2010). The purpose of this strategy was to ensure that students were aware of a more holistic approach to care in the health care setting by developing therapeutic relationships through listening to the lived experiences of older adults and understanding their needs and wants (Berwick, 2009; Corbally & O'Neill, 2014; Jefferies & Horsfall, 2013). This innovative learning strategy was embedded into an undergraduate teaching subject focused on older adults for students enrolled in a 3-year preregistration nursing program. This subject was taught in the final-year final semester with approximately 1,000 students enrolled across three campuses. The strategy could be adapted to any undergraduate or postgraduate nursing curriculum internationally.
Using Biography as a Means of Understanding the Older Adult
To develop this specialized knowledge of the older adult and promote more positive attitudes, nursing students were asked to present a narrative biography of an older adult to understand how a person's present values, beliefs, and circumstances have been shaped by past events (Corbally & O'Neill, 2014; McKeown, Clarke, & Repper, 2006). The biography has two purposes: first, to demonstrate the complexities of caring for the older adult in acute, residential, or community settings, and second, to transform how students value older adults in their own community. Transformational learning occurs when a student's ideas are changed because of the incorporation of new knowledge or experience at an affective level (Herbst, Swengros, & Kinney, 2010). By listening to the biography of the older adult, the students are drawn into their human experience at an emotional level so that students confront their negative assumptions as they reflect and analyze the material from their conversations to produce an overview of the older adult's life to their class (Greenhalgh, Russell, & Swinglehurst, 2005; Joyce, 2015; Kozub, 2013; McNaron, 2009).
The learning strategy endeavored to provide students with knowledge and skills to build relationships so they could understand that each older adult has unique needs that must be considered when treatment and care are being planned. As students reflected on how they could foster a therapeutic relationship by building trust and mutual understanding, students were encouraged to consider the psychosocial aspects so they understood how illness could impact the older adult's quality of life (Epstein, 2000; McCormack et al., 2010; Ross, Tod, & Clarke, 2015). The students listened to the person's biography to understand what influenced their thoughts and feelings toward illness and how the older adult chose to manage it (Charon, 2006; Holmgren, Fuks, Boudreau, Sparks, & Kreiswirth, 2011; McKeown et al., 2006). The students were required to emphasize how the current thoughts and feelings of the older adult were influenced by cultural, spiritual, social, and psychological dimensions of their past lives (Molzahn et al., 2012).
Defining the Older Adult
An older adult is defined as any person who is 65 years or older in western societies (Australian Institute of Health and Welfare [AIHW], 2012). The WHO takes a broader view that includes developing countries and defines the older adult as being 60 years or older (WHO, 2014). However, in indigenous communities, people who are older than 50 years are considered to be older adults as they have a lowered life expectancy (AIHW, 2012; Hatcher & Dixon, 2014).
The Learning Strategy
The learning strategy consisted of eight 2-hour tutorials supported by online learning materials and was offered to final-semester students across all preregistration nursing programs at one of the largest nursing programs in Australia. The strategy divided the eight tutorials into three separate functions: discussing the theoretical aspects of care for older adults, presenting biographies of older adults, and reflecting on what has been learned (Figure 1).
The learning strategy.
Theoretical Aspects of Caring for Older Adults
The first three tutorials focused on theoretical aspects of older adult care and on some of the challenges of care to give the students an understanding of common health problems confronted by older adults.
The second focus was to raise awareness of person-centered care by requiring students to engage with an older adult through a conversation and to reflect on this experience (Doherty & Thompson, 2014). The students presented their biographies and what they learned about the older adult's life story to their class using a flipped classroom approach, an approach that encourages students to prepare content to promote learning in tutorials (McGowan, Balmer, & Chappell, 2014). The only requirements for this presentation were that the older adult was older than 65 years (or older than 50 years if the older adult was of an indigenous background) and that the older adult was living. Students who had recently lost a significant older adult asked to present their life story; however, the emphasis of the program was to ensure that students had an in-depth conversation so they could reflect on the interaction and better understand the skills required when interviewing an older adult in their care (Charon, 2006; Christensen, 2009; Shapiro, 2011). The students' performance was assessed by two methods. First, the academic assessed the presentation, and second the students submitted a written reflection about their own experience of the conversation they had with the older adult (Table 1).
The purpose of the presentation was to bring the various life experiences of older adults into the classroom and to highlight their contributions to both their families and to society. By listening to the biographies of the older adults in the presentations, the students could hear the voice of the older adults in their classroom. The students came to understand how differently each older adult perceived their life experiences and how these differences needed to be incorporated when planning care. To develop an understanding of cultural diversity, students were asked to focus on the cultural and spiritual perspectives of the older adult's life. The students could also present a short biography of their older adult. Empathy was promoted by encouraging the student to consider what aspects of the older adult's life they found most interesting or similar to their own experiences. The point of this approach was to provide a collaborative learning space (Beery, Shell, Gillespie, & Werdman, 2013) where students would come to a new and perhaps more positive understanding of older adults from diverse cultural backgrounds by listening to their life story (McGarry, Aubeeluck, Simpson, & Williams, 2009).
Following their presentation, each student submitted a written reflection about their experience of the conversation with the older adult. Students followed a template developed from Johns's reflective model that asked the student to explore the following aspects of the conversation: first, the student described the setting and his or her feelings during the conversation; second, the student identified three aspects of the conversation that were interesting and related these aspects to his or her own experiences; third, the student reflected on how his or her attitude to older adults changed after their conversation; and finally, the student described how this change of attitude would affect his or her future nursing practice (Johns, 2012, 2013). The purpose of the reflection is to encourage students to uncover how any assumptions or stereotypes of an older person had clouded their view of the older person and compromise the care the student could potentially provide.
The marking criteria was designed to test how well the student was able to communicate with the older adult and how that conversation was incorporated into the student's own practice. First, the student had to describe the impact the conversation had on the student and to assess whether they had skills to develop a therapeutic alliance during the interview. The student then had to identify three aspects of the older adult's life and explain why they were important to the student. Finally, the student was asked to consider how these important aspects of the older adult's life would be used in practice to develop therapeutic relationships with older adults (Ben-Asher & Roskin, 2018).
Reflecting on What Has Been Learned
The third focus offered a space for further reflection on spiritual aspects of older adult care. This was designed to encourage the students to recognize strategies that enhanced understanding of how older adults make meaning of their life and their current lived experience (Mead & Bower, 2000). Poetry was used to explore how confronting the actual voice of the older adult had changed the students' perceptions of ageing (Shapiro, 2011). A poem, “A Crabbit Old Woman,” written by Phyllis McCormack in 1966 while she was working in an aged care unit, was read to the class.
The opening lines of the poem describe how a nurse might see an older adult without engaging with him or her on a personal level:
A crabbit old woman, not very wise,
Uncertain of habit, with far-away eyes,
Who dribbles her food and makes no reply.
The poem then goes on to describe the stages of the older woman's life, such as her childhood, adolescence, young adulthood as she marries and has children, middle age, retirement, and bereavement. The intention of reading this poem is to demonstrate how an older person has had many life experiences that the student can identify. The poem makes the point explicitly in the following lines:
But inside this old carcass, a young girl still dwells,
And now and again my battered heart swells,
I remember the joy, I remember the pain,
And I'm loving and living life over again.
This facilitated discussion about how easy it is to dehumanize an older adult in all health care settings if the nurse does not apply person-centered principles to the care they provide (de Almeida Tavares et al., 2015; MacKinlay, 2012; McCormack, 2003).
Student Reception of Unit
At the beginning of the semester, students were asked whether they intended to make a career in older adult nursing. The majority of students said that their interest lay in other specialties, but all students recognized that in most health care settings they would be caring for older adults (AIHW, 2013). Many students said that they could not remember having an in-depth conversation with an older adult, including a close family member such as a grandparent. The students expressed concerns about not having a close relationship with an older adult and an uncertainty about how to engage in a conversation with the older adult, even if the older adult was a close family member. With guidance from academics, all students could identify an appropriate older adult to interview and develop a presentation to their class.
The value of these presentations was recognized by students when they began to hear the biographies of the older adults. One of the major aspects of these presentations that held the students' interest was the cultural diversity of these biographies (Shellman, 2006). For example, in one tutorial, the students may have heard the lived experience of older adults with Asian, African, European, and Middle-Eastern backgrounds. Often students supplemented their presentations with cultural artefacts such as photographs of the person or their country of origin, personal mementoes, traditional foods, and costumes. Some students also played the traditional music of the older adult's culture (Cipriani et al., 2009). All students were drawn into the life of each older adult and demonstrated an empathetic response to the biography by asking questions at the end of the presentation (Cipriani et al., 2009; MacKinlay, 2012; Makaroff, Shields, & Molzahn, 2013).
One of the most surprising aspects of the presentations was the reactions of some students when presenting the biographies of a close family member. This was because the students said that they found out information about close family members they had never known (Reitmaier et al., 2015). Some of these reactions were expressed in the following manner by students:
- I am close to my grandmother, and I thought I knew her but after the conversation I realized that I never really knew her.
- I used to be very embarrassed by my Dad always talking about fighting in the Vietnam War but since he told me of his experiences, I am now really proud of him.
- I used to think I was doing my grandmother a favor when I visited her, but now I know how much she has done for me.
These reactions, combined with hearing the other presentations, led students to deeply reflect on their attitudes to older adults. As one student said:
I have worked in aged care for seven years but I now recognized that I was very task focused and didn't really listen to the older adults. I will spend more time talking to the older adults in my care to understand them.
The presentations highlighted how much each older adult had contributed or was continuing to contribute to their families and to their communities.
Students explained how the experience of interviewing an adult older influenced their future care, acknowledging that they realized this could be achieved by simply taking the time to get to know the older adult by talking to them (McGarry et al., 2009). These reactions, combined with hearing the other presentations, led students to deeply reflect on their attitudes to older adults. Students planned to spend more time talking to the older adults in their care so they could develop a better understanding of their needs (Chonody, 2015; McKeown et al., 2006). Another important insight was that students came to understand how the life experiences of the older adult had shaped their current character and, in some cases, led to the development of challenging behaviors. Many students stated that an understanding of these life experiences enabled them to look beyond any difficult behaviors to the actual person in their care and provide individualized care based on the person's needs and wants.
The learning strategy is a successful approach to teaching older adult nursing. Its success lies in its ability to challenge students to confront their current attitudes to older adults by giving them an opportunity to immerse themselves in the older adults' lived experiences. Although a limitation of this study was that it was not based on formal research, the authors appreciated how students came to realize the many and varied experiences the older adult spoke about resonated with their own experience or with their hopes and dreams for their own futures. Students were encouraged to see how a person-centered approach changed how they perceived the older adult in their care. The older adult was no longer a burden and, in fact, could be a positive influence on the students' own lives. This approach facilitates how engaging in an in-depth conversation with an older adult can raise awareness of the importance of person-centered principles in preregistration nursing students. Further research will evaluate the effectiveness of this strategy to raise awareness of person-centered care to develop an understanding of how knowing someone's biography can facilitate an empathetic connection between the nurse and the older adult.
- Australian Institute of Health and Welfare. (2012). Australia's health 2012. (AIHW health series no. 13, cat. no. AUS 156). Retrieved from https://www.aihw.gov.au/reports/australias-health/australias-health-2012/contents/table-of-contents
- Australian Institute of Health and Welfare. (2013, April, 19). Rise in hospital admissions for older Australians [Press release]. Retrieved from https://www.aihw.gov.au/news-media/media-releases/2013/2013-apr/rise-in-hospital-admissions-for-older-australians
- Baumbusch, J., Dahlke, S. & Phinney, A. (2012). Nursing students' knowledge and beliefs about care of older adults in a shifting context of nursing education. Journal of Advanced Nursing, 68, 2550–2558. doi:10.1111/j.1365-2648.2012.05958.x [CrossRef]
- Beery, T.A., Shell, D., Gillespie, G. & Werdman, E. (2013). The impact of learning space on teaching behaviors. Nurse Education in Practice, 13, 382–387. doi:10.1016/j.nepr.2012.11.001 [CrossRef]
- Ben-Asher, S. & Roskin, N. (2018). Capturing the moment: Developing a reflective narrative tool for training in the education professions. Asia Pacific Journal of Counselling & Psychotherapy, 9, 143–159. doi:10.1080/21507686.2018.1483412 [CrossRef]
- Berendonk, C. & Caine, V. (2017). Insights into care providers' understandings of life story work with persons with dementia: Findings from a qualitative study. Research & Theory for Nursing Practice, 31, 272–294. doi:10.1891/1541-6522.214.171.1242 [CrossRef]
- Berwick, D.M. (2009). What ‘patient-centered’ should mean: Confessions of an extremist. Health Affairs, 28, w555–w565. doi:10.1377/hlthaff.28.4.w555 [CrossRef]
- Buckley, C., McCormack, B. & Ryan, A. (2018). Working in a storied way—Narrative-based approaches to person-centred care and practice development in older adult residential care settings. Journal of Clinical Nursing, 27, e858–e872. doi:10.1111/jocn.14201 [CrossRef]
- Charon, R. (2006). Narrative medicine: Honoring the stories of illness. Oxford, United Kingdom: Oxford University Press.
- Chonody, J.M. (2015). Addressing ageism in students: A systematic review of the pedagogical intervention literature. Educational Gerontology, 41, 859–887. doi:10.1080/03601277.2015.1059139 [CrossRef]
- Christensen, M. (2009). The consultative process used in outreach: A narrative account. Nursing in Critical Care, 14, 17–25. doi:10.1111/j.1478-5153.2008.00310.x [CrossRef]
- Cipriani, J., Kreider, M., Sapulak, K., Jacobson, M., Skrypski, M. & Sprau, K. (2009). Understanding object attachment and meaning for nursing home residents: An exploratory study, including implications for occupational therapy. Physical & Occupational Therapy in Geriatrics, 27, 405–422. doi:10.3109/02703180903183164 [CrossRef]
- Clendon, J. (2011). Enhancing preparation of undergraduate students for practice in older adult settings. Contemporary Nurse: A Journal for the Australian Nursing Profession, 38, 94–105. doi:10.5172/conu.2011.38.1-2.94 [CrossRef]
- Cline, D.D. (2015). Complexity of care: A concept analysis of older adult health care experiences. Nursing Education Perspectives, 36, 108–113. doi:10.5480/14-1362 [CrossRef]
- Corbally, M. & O'Neill, C.S. (2014). An introduction to the biographical narrative interpretive method. Nurse Researcher, 21, 34–39. doi:10.7748/nr.21.5.34.e1237 [CrossRef]
- de Almeida Tavares, J.P., da Silva, A.L., Sá-Couto, P., Boltz, M. & Capezuti, E. (2015). Portuguese nurses' knowledge of and attitudes toward hospitalized older adults. Scandinavian Journal of Caring Sciences, 29, 51–61. doi:10.1111/scs.12124 [CrossRef]
- Doherty, M. & Thompson, H. (2014). Enhancing person-centred care through the development of a therapeutic relationship. British Journal of Community Nursing, 19, 502–507. doi:10.12968/bjcn.2014.19.10.502 [CrossRef]
- Eaton, J. & Donaldson, G. (2016). Altering nursing student and older adult attitudes through a possible selves ethnodrama. Journal of Professional Nursing, 32, 141–151. doi:10.1016/j.profnurs.2015.10.005 [CrossRef]
- Epstein, R.M. (2000). The science of patient-centered care. The Journal of Family Practice, 49, 805–810.
- Greenhalgh, T., Russell, J. & Swinglehurst, D. (2005). Narrative methods in quality improvement research. Quality & Safety in Health Care, 14, 443–449. doi:10.1136/qshc.2005.014712 [CrossRef]
- Hatcher, D. & Dixon, K. (2014). Primary healthcare and the older person. In Johnson, A. & Chang, E. (Eds.),Caring for older people in Australia (pp. 1–25). Milton, Queensland, Australia: Wiley.
- Herbst, A.M., Swengros, D.I. & Kinney, G. (2010). How to teach human caring: Nurse educator role in transformational learning for a large healthcare system. Journal for Nurses in Staff Development, 26, E6–E11. doi:10.1097/NND.0b013e3181b1ba55 [CrossRef]
- Holmgren, L., Fuks, A., Boudreau, D., Sparks, T. & Kreiswirth, M. (2011). Terminology and praxis: Clarifying the scope of narrative in medicine. Literature and Medicine, 29, 246–273. doi:10.1353/lm.2011.0323 [CrossRef]
- Jefferies, D. & Horsfall, D. (2013). Developing person centred care through the use of autobiography. International Practice Development Journal, 3, 1–17.
- Johns, C. (2012). How holistic are we? The role of narrative, storytelling and reflection in the development of holistic practice. European Journal of Cancer Care, 21, 561–564. doi:10.1111/j.1365-2354.2012.01374.x [CrossRef]
- Johns, C. (2013). Becoming a reflective practitioner (3rd ed.). Oxford, United Kingdom: Wiley & Sons.
- Joyce, M. (2015). Using narrative in nursing research. Nursing Standard, 29, 36–41. doi:10.7748/ns.29.38.36.e9008 [CrossRef]
- Kozub, M.L. (2013). Through the eyes of the other: Using event analysis to build cultural competence. Journal of Transcultural Nursing, 24, 313–318. doi:10.1177/1043659613481809 [CrossRef]
- MacKinlay, E. (2012). Resistance, resilience, and change: The person and dementia. Journal of Religion, Spirituality & Aging, 24, 80–92. doi:10.1080/15528030.2012.633048 [CrossRef]
- Makaroff, K.S., Shields, L. & Molzahn, A. (2013). Symbolic representations of living with chronic kidney disease. Nephrology Nursing Journal, 40, 517–526.
- McCormack, B. (2003). A conceptual framework for person-centred practice with older people. International Journal of Nursing Practice, 9, 202–209. doi:10.1046/j.1440-172X.2003.00423.x [CrossRef]
- McCormack, B., Karlsson, B., Dewing, J. & Lerdal, A. (2010). Exploring person-centredness: A qualitative meta-synthesis of four studies. Scandinavian Journal of Caring Sciences, 24, 620–634. doi:10.1111/j.1471-6712.2010.00814.x [CrossRef]
- McCormack, P. (1966). A crabbit old woman. Retrieved from http://www.alicechilton.com/news/crabbit-old-woman
- McGarry, J., Aubeeluck, A., Simpson, C. & Williams, G. (2009). Nursing students' experiences of care. Nursing Older People, 21, 16–22. doi:10.7748/nop2009.09.21.7.16.c7276 [CrossRef]
- McGowan, B.S., Balmer, J.T. & Chappell, K. (2014). Flipping the classroom: A data-driven model for nursing education. The Journal of Continuing Education in Nursing, 45, 477–478. doi:10.3928/00220124-20141027-11 [CrossRef]
- McKeown, J., Clarke, A. & Repper, J. (2006). Life story work in health and social care: Systematic literature review. Journal of Advanced Nursing, 55, 237–247. doi:10.1111/j.1365-2648.2006.03897.x [CrossRef]
- McNaron, M.E. (2009). Using transformational learning principles to changer behaviour in the OR. AORN Journal, 89, 851–860. doi:10.1016/j.aorn.2009.01.027 [CrossRef]
- Mead, N. & Bower, P. (2000). Patient-centredness: A conceptual framework and review of empirical literature. Social Science & Medicine, 51, 1087–1110. doi:10.1016/S0277-9536(00)00098-8 [CrossRef]
- Molzahn, A., Sheilds, L., Bruce, A., Stajduhar, K., Schick Makaroff, K., Beuthin, R. & Shermak, S. (2012). People living with serious illness: Stories of spirituality. Journal of Clinical Nursing, 21, 2347–2356. doi:10.1111/j.1365-2702.2012.04196.x [CrossRef]
- Reitmaier, A., Davies, S., Reveling Smith, L., Mangan-Danckwart, D., Hongerholt, K. & Klinkner, J. (2015). Discovering intergenerativity: An evaluation of learning partnerships between student nurses and older adults. International Journal of Older People Nursing, 10, 115–126. doi:10.1111/opn.12061 [CrossRef]
- Ross, H., Tod, A.M. & Clarke, A. (2015). Understanding and achieving person-centred care: The nurse perspective. Journal of Clinical Nursing, 24, 1223–1233. doi:10.1111/jocn.12662 [CrossRef]
- Shapiro, J. (2011). Illness narratives: Reliability, authenticity and the empathic witness. Medical Humanities, 37, 68–72. doi:10.1136/jmh.2011.007328 [CrossRef]
- Shellman, J. (2006). Making a connection: BSN students' perception of their reminiscence experiences with older adults. Journal of Nursing Education, 45, 497–503.
- World Health Organization. (2015). Age and health. Geneva, Switzerland: Author.
|Describe in detail the impact your conversation with the older person has had on you.|
|Following your description in Question 1, identify and describe the three (3) aspects that were most important and/or interesting.|
|Why are these three aspects either important and/or interesting to you? Remember, this is a reflection, so it will be useful to draw on your personal experiences as you consider your response to this question.|
|Has your conversation (and those you have heard from your peers) changed your ideas about the lives of older people? Explain your answer.|
|Describe how your conversation could have a positive impact on your nursing practice.|