As the number of older adults in America grows, the need for evidence-based geriatric care is also increasing. By 2060, nearly one in four Americans will be 65 years and older, and the number of adults over the age of 85 is projected to triple (U.S. Census Bureau, 2020). Nursing students are entering the profession to care for this growing population, often without understanding the unique needs of older adults. Geriatric care is typically restricted to a few lessons set apart from the broader curriculum and comprising an estimated 5% of educational content (Negrin & Dahlke, 2019). Newly licensed nurses will need to recall and apply this content daily upon graduation when caring for the large population of older adults. This disconnect between theoretical knowledge and clinical application contributes to the practice gap that new graduate nurses experience upon entering the profession (Bennett et al., 2017).
To prepare nursing students to meet the needs of the aging patient population, innovative teaching methods are needed that foster a mindset for evidence-based practice (EBP) to help older adults thrive. A hybrid teaching model was developed to bridge classroom and clinical education and bring geriatric care to the forefront of the student experience. Troutman-Jordan's (2014) theory of successful aging was used as a framework to inform nursing care of the older adult. This theory prioritizes the ability to adapt to the changes of aging and progress toward gerotranscendence (Tornstam, 1989).
The foundational coping processes defined in the theory as intrapsychic factors, spirituality, and functional performance mechanisms were reinforced at each step of the teaching model (Troutman-Jordan & Staples, 2014). Intrapsychic factors are defined as personal characteristics in the mental, emotional, and psychosocial dimensions that help an individual cope with change. Spirituality includes views and behaviors that connect the individual to something greater than oneself. Functional performance mechanisms encompass awareness of the physiologic changes of aging and making choices to maintain optimal safety and independence.
The theoretical precepts were studied on three separate occasions using a multimodal approach. Each step of the process incorporated a different teaching method targeted to the four learning styles of the Visual, Aural, Read/write, and Kinesthetic (VARK) model (Fleming, 1995). The first lesson relied on visual and aural learning, kinesthetic in the clinical setting, and reading and writing in the final classroom lesson. Repetition and practical application were used to enhance retention and recall.
Beyond the Classroom
Twenty-seven students in a practical nursing program participated in this three-part hybrid of clinical and classroom education. The lessons took place over the course of 1 week in both classroom and clinical settings to reinforce the content and allow students to integrate geriatric nursing theory in direct patient care. The students had no prior knowledge of the theory of successful aging. This was confirmed by a curriculum review and student self-report prior to the first lesson.
Students first received a theory lesson using a traditional learning model in the classroom setting. The theory was presented via lecture with a PowerPoint® presentation and was followed by a pretest to assess comprehension based on a traditional approach. The intervention included two additional steps to foster application and integration of the theory, as outlined in the standards for nursing scholarship (American Association of Colleges of Nursing, 1999). This format maximized the use of educational best practices to teach students the process of employing EBP.
In the clinical setting, students were given clear guidelines and requirements to apply theoretical knowledge in a practical way. Students completed a 12-point assessment worksheet highlighting intrapsychic factors, spirituality, and functional performance mechanisms (Troutman-Jordan & Staples, 2014). The worksheet was structured with four assessment goals for each of these three coping processes. It was designed to guide students in learning about their patients' needs in relation to the theoretical precepts. The assessment worksheet was then brought to class to continue the third component of the hybrid lesson.
At the final meeting, students used their assessment worksheets to develop concept maps outlining patient care goals. The concept maps were presented in a group discussion format to support peer communication and integration of the theory. Students discussed their findings, shared their experiences, and demonstrated increased awareness of the needs of older adults.
To evaluate the effectiveness of this teaching model, students were observed during the group discussion and a pre- and posttest were administered with an open response survey. The pretest was given at the end of the first class meeting to assess comprehension of the content in a traditional lecture format. The posttest was given at the completion of the three-session hybrid model to assess for student improvement and retention of the content.
After the intervention, 45% of test scores increased, and 89% of students reported a greater understanding of the theory. Students with the lowest pretest scores increased the most profoundly, whereas students with higher pretest scores tended to stay the same or increase marginally. This evidenced important gains for many students after participating in the educational hybrid.
The pretest identified a small percentage of students who grasped the theory in lecture format but could not estimate the student's ability to apply this knowledge in the clinical setting. Two students who initially performed well on the pretest did not retain all the content from the lecture, and their scores decreased on the posttest. This outcome highlights the concern that test performance alone may not indicate proficiency that translates to clinical practice. These findings point to the need for application and integration methods to increase retention even when learners appear to thrive in a traditional lecture format.
The students expressed strong support for this intervention, with 89% reporting that they understood the theory better after the interactive learning model. Anecdotal comments about the experience included, “I liked taking the quiz a second time around because I did indeed understand the concepts better.” In the group discussion, students demonstrated increased awareness of the needs of geriatric patients and exhibited greater confidence in assessing the needs of this patient population. Students also identified challenges such as limited opportunities for social or spiritual outlets in long-term care, confirming a greater awareness of the needs of older adults.
Preparing for Implementation
The challenge of this process was primarily in structuring continuity between classroom and clinical settings. Effective communication with all clinical instructors was vital to the success of the project. Clinical instructors were brought together with the theory instructor through a virtual presentation online to review the theory of successful aging and expectations for students at clinical. The information was provided in a format accessible to staff at the clinical site who could not meet on campus.
Although the lessons took place over 3 days, the content accounted for only 1 hour and 30 minutes of classroom time. At the clinical site it was completed alongside all other requirements scheduled in a typical clinical day. Considering the marked student improvements and small-time input, the return on investment is promising. This intervention is structured to fit into the current academic model with minimal disruption and maximum effectiveness to enhance the academic experience.
This educational hybrid was designed to decrease the practice gap that students experience as newly licensed nurses caring for the older adult patient population. The theory of successful aging provides a clear framework that educators can use to instruct students and guide them in providing evidence-based care. The importance of EBP is impressed upon students, but many still struggle to understand what it is and how to integrate it into clinical practice. Students are led through this process beginning with the best available research in the classroom, moving to clinical application, and finally integrating theory into ongoing nursing practice through peer discussion and reflection.
This three-pronged approach addresses the needs of a wide range of learners and prepares students to meet the demands of today's health care environment. Nurses who can recall and apply EBP with this large segment of the patient population will be prepared for success upon graduation instead of facing a practice gap that overwhelms many (Bennett et al., 2017). This differentiates a novice from a proficient nurse who has developed judgement toward geriatric care. By learning how to effectively integrate theory into practice, students develop nursing judgement that will follow them throughout their careers and improve the scope of care for the geriatric population.
- American Association of Colleges of Nursing. (1999). Defining scholarship for the discipline of nursing. from https://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Defining-Scholarship
- Bennett, L. L., Grimsley, A., Grimsley, L. & Rodd, J. (2017). The gap between nursing education and clinical skills. The ABNF Journal, 28(4), 96–102 http://libill.hartford.edu:2048/login?url=https://libill.hartford.edu:2204/docview/2039834640?accountid=11308
- Fleming, N. D. (1995). I'm different; not dumb. Modes of presentation (VARK) in the tertiary classroom. Higher Education Research & Development, 18, 308–313 http://www.vark-learn.com/wp-content/uploads/2014/08/different_not_dumb.pdf
- Negrin, K. & Dahlke, S. (2019). Examining nursing education: A call to action. Perspectives, 40(3), 17–25 https://libill.hartford.edu:2204/docview/2248998668?accountid=11308
- Tornstam, L. (1989). Gero-transcendence: A reformulation of the disengagement theory. Aging, 1(1), 55–63 doi:10.1007/bf03323876 [CrossRef] PMID:2488301
- Troutman-Jordan, M. & Staples, J. (2014). Successful aging from the viewpoint of older adults. Research and Theory for Nursing Practice, 28(1), 87–104 doi:10.1891/1541-65188.8.131.52 [CrossRef] PMID:24772609
- U.S. Census Bureau. (2020). Demographic turning points for the United States: Population projections for 2020 to 2060. https://www.census.gov/library/publications/2020/demo/p25-1144.html