By 2050, the population of older adults in the United States is expected to be 83.7 million, which is nearly double in size from 43 million in 2012 (U.S. Census Bureau, 2014). Two of every three older adults live with multiple chronic conditions and nearly 80% has at least one chronic illness (Centers for Disease Control and Prevention, 2013). Individuals aged 65 years and older utilize more health care services, including physician office, hospital, emergency department, and home health visits, than any other age group (National Center for Health Statistics, 2015). RNs provide much of the care for the increasing aging population, yet there is a lack of comprehensive education focused on the geriatric patient, with nearly 60% of baccalaureate programs not having a required geriatric course (American Association of Colleges of Nursing, 2010). In addition to developing evidence-based knowledge and skills in the care of older adults, geriatric curricula should also influence students' overall attitudes about aging (King, Roberts, & Bowers, 2013). This includes educating students' regarding ageism and common misconceptions about older adults. The attitudes clinicians have about patients can influence quality of care (Neville & Dickie, 2014); therefore, it is critical that nursing education focus on fostering both knowledge and attitudes toward older adults.
Students' Knowledge and Attitudes Toward Aging
Prior knowledge is often based on myths and misconceptions about aging, which can also affect attitude toward a particular group of people. Ouchida and Lachs (2015) found that ageism among health care professionals can contribute to the under- or overtreatment of older adults. They also reported that one of the contributing factors to ageism among health care professionals is the constant exposure to older adults who are ill, with limited or no exposure to those who are healthfully aging. Having a misguided or incorrect perception about older adults can also affect students' attitudes toward the aged. Therefore, most of research that focuses on improving students' knowledge about aging also includes a focus on attitude. Boswell (2012) investigated the efficacy of a gerontology education course containing 43 undergraduates, and their findings with a supported study hypothesis that ageism scores decreased and knowledge scores increased by the end of the course. Based on the literature surrounding this topic, a specific course or educational training focused on aging is associated with improvements in aging-related knowledge.
Although knowledge scores tend to improve with formal education or training in aging, improvements in overall attitudes toward older adults have produced mixed results. Mattos et al. (2015) found that although students who participated in a gerontology nursing course had higher knowledge scores, there were no differences in attitude scores. In a recent systematic review that examined nurses' attitudes toward older adults, preferences to work with older adults and greater aging knowledge were found to be associated with a more positive attitude toward aging (Liu, Norman, & While, 2013). Given that most of the previous research on this topic has been cross-sectional, King et al. (2013) took a longitudinal approach to describe nursing students' attitudes and preferences over time. Although attitudes improved over time, findings suggest that students' clinical placements in their nursing program played a role in whether they plan to work with older adults in the future.
Interest in Older Adults
An increased knowledge and better attitude toward older adults may increase students' overall interest and desire to work with this population after graduation. A national survey that examined interest in working with older adults in a large sample of 486 nursing students found that a positive attitude toward older adults was most predictive of geriatrics as a future career choice (Haron, Levy, Albagli, Rotstein, & Riba, 2013). The negative portrayal of aging on the development of disease processes was found to be a factor associated with development of a negative attitude among a sample of medical students (Higashi, Tillack, Steinman, Harper, & Johnston, 2012). The clinical experiences of students during their educational program, whether medical or nursing, appear to affect their desire to work with specific populations or settings.
The purpose of this study was to examine whether the introduction of a stand-alone geriatric nursing course improved the knowledge, attitude, and interest in older adults among undergraduate nursing students compared with students in a previous cohort who did not receive the course.
Aim 1 was to describe and compare students' knowledge and attitudes towards aging. Aim 2 was to examine whether completion of the geriatric class was associated with a greater interest in working with the older adult population. Aim 3 was to explore the perspectives of students who completed the geriatric course.
A cross-sectional mixed-methods descriptive study was used to compare two cohorts of undergraduate nursing students in the final semester of their degree program. The sample consisted of senior nursing students enrolled in a traditional baccalaureate nursing program at a public college in Western New York. Data collection for the first cohort occurred during the year prior to initiation of the geriatric course. Students who completed the geriatric course during the following year were invited to participate in data collection for the second cohort. The geriatric course was developed based on the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults (American Association of Colleges of Nursing, 2010). Approval was granted from the university institutional review board before data collection took place.
Data were collected using a 49-item online questionnaire administered through SurveyMonkey™. This contained four separate questionnaires that were combined into one 49-item survey. Aging-related knowledge was measured using Palmore's Facts on Aging Quiz. This is a 25-item true-or-false scale that is a well-known, reliable, and valid instrument used to assess knowledge of aging (Palmore, 1977). Attitudes toward older adults were measured using items obtained from the Kogan Attitudes Towards Older Adults Scale (Kogan, 1961). Items on this scale are either positively or negatively worded, and the respondent's level of agreement with each item is measured. Reliability coefficients for this scale range from .66 to .77 for positively worded items and .73 to .83 for negatively worded items (King et al., 2013).
Demographic items included age, gender, ethnicity, grade point average, previous college course or training in aging, and any previous experience caring for an older adult. Interest in working with older adults was measured using an open-ended question that asked their intent about working with the older adult population in the future and overall perspectives about the population after completing the course.
Survey data were entered into SPSS 22.0 software. Descriptive statistics, including frequency counts, percentages, and means, were completed with the study variables. Independent t test analyses were used to examine knowledge of aging and attitude toward older adults between the two cohorts. Open-ended qualitative data were entered into Atlas ti 8.0 software and analyzed using a qualitative descriptive analysis approach. Responses between cohorts were compared.
A convenience sample of 46 students completed the survey (20 students from the first cohort and 26 students from the second cohort). This was a relatively low (34%) response rate from students who were eligible to participate.
The total sample was predominately female (78%), White (96%), with a mean age of 24.8 years (range = 21 to 44 years). The mean grade point average was 3.53. The majority of the sample had never received any other training in geriatrics (i.e., a previous college course other than the course taken by the second cohort). No demographic differences were found between cohorts. The only notable differences found between cohorts was that over half (58%) of the students in the second cohort reported they currently work with older adults, compared with only 35% in the first cohort. The majority of students in the second cohort had no prior experience caring for an aging relative (92%), compared with over half (62%) of the first cohort having had previous experience.
An independent samples t test was conducted to compare aging-related knowledge between students who did and did not take a geriatric course. There were no significant differences of scores in the first cohort who did not take the geriatric course (M = 63.1, SD = 8.51) and the second cohort who completed the geriatric course (M = 66.9, SD = 11.1); t (39) = −1.21, p = .233. These results suggest that the completion of the geriatric course did not have an effect on aging-related knowledge in the sample of undergraduate nursing students.
Attitudes and Interest Toward Older Adults
An independent samples t test was conducted to compare attitudes toward older adults in students who did and did not take a geriatric course. There was not a significant difference in the scores for the cohort who did not take the geriatric course (M = 3.5, SD = .317) and the cohort who completed the geriatric course (M = 3.6, SD = .320); t (40) = −.195, p = .846. These results suggest that the completion of the geriatric course did not have an effect on attitudes toward older adults in this sample of undergraduate nursing students.
Students in the second cohort, who completed the geriatric course, were asked questions regarding their interest in working with older adults after graduating from the nursing program. Students in the first cohort were not asked this question. Only 35% of students reported an interest in working with the older adult population, whereas 65% of students reported they did not want to work with older adults.
Analysis of Qualitative Data
Analysis of the narrative data derived from participants' responses to open-ended questions about the geriatric course resulted in two main themes.
Changed Knowledge About Aging Related Myths. The most common theme related to students' changed perspectives surrounding aging related myths. The majority of students felt more knowledgeable about the care of older adults, and the most common comment related to this was their changed knowledge about the many misconceptions they had about older adults, prior to taking this class. One of the students wrote, “The information in this class cleared up a lot of inconsistencies I had about older people, like that not all old people get dementia.” Students also found the assignments helped to solidify the content by enabling them to better understand the daily life experienced by older adults, including common needs and concerns. One student expressed, “The future perspectives assignment forced me to think about my own mortality and what challenges I would be facing as I get older.”
Timing of the Course in the Program. One of the common narratives expressed by students in their open-ended responses was about the timing of the geriatric class in the program. Students reported a preference to have this course during their first semester. The students engage in a 1-day shadowing experience at a local long-term–care facility and many students said that they wished they would have known some of the things learned from this class prior to their interaction with residents. One student wrote, “So many of us were freaking out when the residents were yelling, and we got scared because we did not know what was wrong with them.” Another student said that he believed the lack of a concurrent clinical rotation made the course less effective than other courses with a clinical component. He said, “I found the class interesting but wished I would be able to apply what I learned in the clinical setting; instead I had maternity clinical where all I got to see was moms and babies.”
Findings from this cross-sectional pilot study show that there were no significant differences in knowledge or attitudes between students who did or did not take a stand-alone geriatrics course. Although no baseline data were obtained, the addition of the class did not improve knowledge or attitudes scores among the second cohort. No marked differences between cohorts were noted, except for the first cohort having experience caring for an aging relative. The second cohort consisted of more students who were currently working in a setting with older adults.
Although students in the first cohort were not asked about their interest in working with older adults and were unable to give their perspectives about the course, findings from the second cohort provided both positive and negative perspectives about the geriatric course. The clarification of aging-related myths and misconceptions were identified as the most positive aspect of the geriatrics course. Students were able to learn accurate information about aging and age-related changes in older adults. This supports previous research that found geriatric education helped to dispel myths and preconceived notions students had about older adults (King et al., 2013). Students also indicated that the course assignments helped to better understand what older adults' daily life is like and their needs and concerns.
On another note, the majority of students indicated a decreased desire to work with older adults after graduation. Students did not provide narrative comments to explain why this response; however, they provided good narrative data about the geriatric course. Students' expressed a desire to change the timing of when the course is offered. Some participants noted that having it in the first semester of the program would help them connect with their one clinical experience with older adults living in long-term care, which can influence interest (Neville & Dickie, 2014).
Findings from this small pilot study are limited in scope because the sample originated from one site, lacked baseline data, and was homogeneous. These limitations, along with contamination and maturation issues, threaten the validity of this and other studies that focus on examining the scholarship of teaching and learning. Although Palmore's instrument has been used in numerous studies across disciplines to evaluate aging-related knowledge, an instrument with better sensitivity and specificity may have been better able to detect any improvements in aging-related knowledge. Further research with a larger sample size, multiple sites, and the addition of baseline data, would help to strengthen the methodological rigor of this type of research design. Findings from this study might be a useful starting point for nurse educators to discuss the delivery of their geriatric curriculum within their nursing education program.
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