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Assessment of Geriatric Knowledge: An Online Tool for Appraising Entering APN Students
ASSESSMENT OF GERIATRIC KNOWLEDGE: AN ONLINE TOOL FOR APPRAISING ENTERING APN STUDENTS ELIZABETH M. TOWNER, PHD, FNP* As the percentage of elderly in the U.S. rises, the need for primary health care for the aging population increases. Knowledge of special characteristics of older persons, as well as demographics of the aging population, resources and principles of care are important in the provision of effective, professional primary health care by advanced practice nurses. In response to this increasing need for geriatric health care expertise, a tool was developed to evaluate basic geriatric knowledge of students entering advanced practice nursing study, Self Assessment of Geriatric Knowledge . The Self Assessment , derived from AACN’s recommended geriatric competencies for BSN graduates, may be accessed on-line. Immediate test results are received on-line. Tests completed by 158 advanced practice students over a three year period showed geriatric knowledge deficits: myths of aging, prevention strategies and risk factors of elders; roles and responsibilities for care of elderly persons in the community; health policies that affect elder care; and, demographics of the geriatric population. These data may contribute to faculty awareness of curricular needs for preparing students for competent geriatric nursing care of the growing older population. (Index words: Geriatrics; Advanced practice nurses; Self assessment) J Prof Nurs 22:112–115, 2006. A 2006 Elsevier Inc. All rights reserved.
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TATISTICS HAVE SHOWN an 80% increase in the elder populace since 1920 and predict that, by 2030, 20% of U.S. residents will be over 65 years; among those, half will be over 80 years (Agency on Aging, 2000). According to the American Association of Colleges of Nursing [AACN] and The John A. Hartford Foundation Institute for Geriatric Nursing [Hartford] (2000), bthe predominant health problems of older people are chronic rather than acute and are exacerbated by the normal changes of aging and the increased risk of illness associated with old ageQ (p. 1). Nursing education needs particular preparation regarding these special needs of the elderly. Furthermore, AACN and Hartford state, bUnfortunately, most nurses practicing today have limited preparation in the principles of geriatric nursing careQ (p. 1). In response to the rapid growth rate of our nation’s elder population and to an increasing need for an augmented knowledge base for nurses who care for these older persons, the Association for Gerontology in
*Educational Consultant, formerly, Professor, College of Graduate Nursing, Western University of Health Sciences, Pomona, CA. Address correspondence and reprint requests to Dr. Towner: College of Graduate Nursing, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766. E-mail: [email protected] 8755-7223/$ - see front matter
112 doi:10.1016/j.profnurs.2006.01.004
Higher Education, the National League for Nursing, and the Bureau of Health Professions formed a task force in 1995, which recommended the creation of geriatric competencies for baccalaureate-prepared nurses (as cited in AACN and Hartford, 2000). These recommended competencies were incorporated into the Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998). In 2000, The John A. Hartford Foundation and the AACN awarded grants to graduate nursing programs for the development of geriatric nursing education resources. Thus supported, the Western University Health Science Center developed an online SelfAssessment of Geriatric Knowledge (sometimes referred to as Pretest) to determine the preparation levels of entering advanced practice nursing (APN) students. The Pretest provided information regarding nursing students’ geriatric knowledge.
Description of Geriatric Knowledge Self-Assessment Tool The above-cited Essentials of Baccalaureate Education for Professional Nursing Practice guided the formulation of 12 objectives addressed in 50 self-assessment questions (see Table 1 for the list of objectives). Dr. Meg Walhagen, geriatric nurse practitioner, project consultant, and content expert, created this list of objectives.
Journal of Professional Nursing, Vol 22, No 2 (March–April), 2006: pp 112– 115 A 2006 Elsevier Inc. All rights reserved.
ASSESSMENT OF GERIATRIC KNOWLEDGE
Table 1. Objectives for the Self-Assessment of Geriatric Knowledge Students Should Be Able To: (1) Understand current and projected demographic characteristics of the older population (z65 years) and their relationship with the health care system and nursing practice. (2) Identify myths of aging and their impact on the care provided to older adults and their families. (3) Differentiate between common normal changes and pathologic changes. (4) Describe the goals of health care of the elderly, based on their special needs. (5) Recognize how changes that occur with age influence the presentation of acute and chronic problems, as well as their response to various treatment modalities. (6) Identify risk factors and measures used for prevention that are important for the care of older adults. (7) Identify established tools that are used to assess the functional status (physical, cognitive, and psychosocial) of older adults. (8) Recognize common geriatric syndromes and delineate approaches to their management (i.e., falls, incontinence, iatrogenesis, polypharmacy, dementia, and delirium). (9) Delineate the role of family and friends in providing care to community-dwelling elders. (10) Adapt teaching strategies to the needs of older adults based on an understanding of physical, cognitive, and psychosocial changes that occur with age. (11) Describe how health care policies and the current health care system influence access to resources and care decisions. (12) Define and differentiate approaches to delineating the health care wishes of older adults.
The self-assessment test addresses basic knowledge and skills necessary for the generalist nurse to provide competent geriatric health care; it is not a comprehensive summary of skills needed by a geriatric nurse specialist. Test questions address the recommended objectives and endeavor to prescribe a compliment of geriatric competencies needed by participating students, with varying depths for each targeted idea. Some objectives are incorporated into as many as nine questions, whereas others require fewer questions. For instance, Objective 5: bRecognize how changes that occur with aging influence the presentation of acute and chronic problems and responses to treatmentsQ spreads itself out among the greatest number of questions. The Self-Assessment of Geriatric Knowledge is selfadministered online and may be completed on any personal computer (PC). Test results are sent to each student immediately, as well as to the faculty. Examples of questions, as presented in the test, are shown in Table 2. Test results show the correct answer and the student’s answer, as well as the individual’s overall score. A student receives, per incorrect answer, online references that may be accessed instantly by clicking on the reference links. The sources of these references include
113
the Gerontological Nursing Certification Review Course of the John A. Hartford Foundation for Geriatric Nursing (n.d.), The Merck Manual of Geriatrics (n.d.), and other professional online resources. These references, linked to individual questions, provide the students with immediate remedial opportunities. The process of test completion is relatively uncomplicated: (1) The responsible faculty member registers a group of students at www.geriatriceducation.org; (2) a password is received online; (3) then, students may log in from any PC, complete the 50 item test, and receive immediate results. The registering faculty member also receives the results. Such data are designed to provide useful information to faculty members who plan to incorporate geriatric content into their curriculum.
Self-Assessment Test Participants and Results All family nurse practitioner students entering the Western University College of Graduate Nursing between 2001 and 2003 (the period of data collection) completed the Pretest. During those 3 years, graduate nursing students from eight other university nursing programs also completed the self-assessment test, with 158 APN students participating. The faculty from these eight programs volunteered to test their students in response to information provided through the Hartford Geriatric Nursing Initiative listserve. Participant data show that 49% were over 40 years old, and 60% had more than 5 years of nursing experience. These data indicate that approximately half of this group of students entering APN programs may have completed a Bachelor of Science in Nursing (BSN) several years prior to graduate school enrollment. These students were at risk for limited preparation in geriatric principles, as noted by Fulmer and Matzo in their study of nursing curricula, as cited in AACN and Hartford (2000).
Table 2. Examples of Pretest Questions (1) Which of the following statements most accurately describes the U.S. population 65 years old and above? o (A) The majority of older adults (65 years and older) are female. o (B) In the past 10 years, the number of individuals over 85 years has been declining. o (C) African American women outlive their Caucasian counterparts by 3–5 years. o (D) More than 35% of persons over 80 years are in nursing homes at any given time. o (E) A and C (2) In terms of the total population, the most rapidly growing segment of the population in the United States is the segment: o (A) Between the ages of 65 and 70 years o (B) Between the ages of 70 and 75 years o (C) Between the ages of 75 and 80 years o (D) Between the ages of 80 and 85 years o (E) 85 years and older
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Figure 1.
Comparison of mean scores, by objective and total mean score.
Self-assessment test results are reported as total scores and according to test objectives to describe competencies in each content area. Mean total scores varied from 51% to 54% for the group of 158 test takers over the 3 years. Scores compiled for each of the 12 objectives showed noteworthy differences. Results are reported by percentages due to differences in the numbers of questions for each objective, as described above. Figure 1 shows comparisons of the 12 objectives. This graph compares the mean scores of each objective in tests completed by students from five programs from June to August 2003. Results from previous test takers were similar. The 2003 mean scores (n = 63) indicated an understanding of teaching strategies (M = 94% correct), of goals of the health care of the elderly (M = 74% correct), and the presentation of symptoms in the aged and their responses to medications (M = 64% correct). Lower mean scores were clustered for these five objectives: normal age changes versus pathological changes (58%); recognizing geriatric syndromes (58%); tools to assess functional status (55%); carrying out health care wishes (54%); and myths of aging (52%). Results also showed some important aspects of geriatric health care with mean scores of less than 50%: prevention strategies and risk assessment (49%) and role assumption for the care of elders in the community (46%). Demographic data in the United States (35%) and knowledge of services by the health
care system for the elderly (35%) displayed the lowest mean scores for these test takers. Interestingly, no significant differences in mean scores were seen in these subjects when compared by age, academic degree, or work setting experience. In addition, scores were examined relative to nursing experience, geriatric nursing experience, and completion of geriatric course. No significant differences were shown.
Conclusions Conclusions from this test analysis should be related only to this group of participants. These data represent a preliminary description of BSN graduates’ geriatric competency, from which no generalizations can be generated. These levels of mean score, both overall means and means for individual objectives, demonstrate a need for expanded geriatric content in BSN education. These participants had the greatest deficits in the following areas: myths of aging, prevention strategies and risk factors, roles and responsibilities for the care of elderly persons in the community, health policies that affect elder care, and demographic data of our geriatric population. Clearly, the BSN curriculum should not only increase student knowledge about the direct treatment of elders, but should also increase student awareness of elder health care’s political and social context.
ASSESSMENT OF GERIATRIC KNOWLEDGE
Recommendations The test tool should be evaluated by faculty members for reliability and validity by increasing the number and variety of test takers over time and by continually scrutinizing the breadth of content being examined. These data suggest the need for systematic assessment and enhancement of BSN geriatric content. Neither the Self-Assessment of Geriatric Knowledge nor the results from these 158 test takers are meant to be conclusive, but they do provide an exploration of the varied gerontology nursing knowledge levels of entering graduate students. These project results contribute to faculty awareness of curricular needs— to prepare students for competent geriatric nursing care of the growing older population. The Self-Assessment of Geriatric Knowledge, with further development and evaluation, may assist the faculty in assessing the gerontological nursing competencies of BSN graduates for the next several years. Significantly improved test scores will indicate sufficient and appropriate expansion of geriatric content in BSN curricula. The Self-Assessment of Geriatric Knowledge could also be considered for
115
precourse and postcourse assessments for curriculum evaluation and for the assessment of a geriatric nurse’s preparation.
References Agency on Aging. (2000). Older Americans 2000: Key indicators of wellbeing: Federal interagency forum on agingrelated statistics. Retrieved on July 11, 2005 from http:// agingstats.gov/chartbook2000/population.html. American Association of Colleges of Nursing [AACN]. (1998). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing [AACN], & The John A. Hartford Foundation Institute for Geriatric Nursing [Hartford]. (2000). Older adults: Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care. Retrieved July 11, 2005, from www.aacn.nch. edu/Education/gercomp. John A. Hartford Foundation for Geriatric Nursing. (2004). Gerontological nursing certification review course. Retrieved July 11, 2005, from http://education.nyu.edu/nursing/ hartford.institute/course/. The Merck manual of geriatrics (3rd ed.). Retrieved July 11, 2005, from www.merckbooks.com/mgeri/.
S
TATISTICS HAVE SHOWN an 80% increase in the elder populace since 1920 and predict that, by 2030, 20% of U.S. residents will be over 65 years; among those, half will be over 80 years (Agency on Aging, 2000). According to the American Association of Colleges of Nursing [AACN] and The John A. Hartford Foundation Institute for Geriatric Nursing [Hartford] (2000), bthe predominant health problems of older people are chronic rather than acute and are exacerbated by the normal changes of aging and the increased risk of illness associated with old ageQ (p. 1). Nursing education needs particular preparation regarding these special needs of the elderly. Furthermore, AACN and Hartford state, bUnfortunately, most nurses practicing today have limited preparation in the principles of geriatric nursing careQ (p. 1). In response to the rapid growth rate of our nation’s elder population and to an increasing need for an augmented knowledge base for nurses who care for these older persons, the Association for Gerontology in
*Educational Consultant, formerly, Professor, College of Graduate Nursing, Western University of Health Sciences, Pomona, CA. Address correspondence and reprint requests to Dr. Towner: College of Graduate Nursing, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766. E-mail: [email protected] 8755-7223/$ - see front matter
112 doi:10.1016/j.profnurs.2006.01.004
Higher Education, the National League for Nursing, and the Bureau of Health Professions formed a task force in 1995, which recommended the creation of geriatric competencies for baccalaureate-prepared nurses (as cited in AACN and Hartford, 2000). These recommended competencies were incorporated into the Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998). In 2000, The John A. Hartford Foundation and the AACN awarded grants to graduate nursing programs for the development of geriatric nursing education resources. Thus supported, the Western University Health Science Center developed an online SelfAssessment of Geriatric Knowledge (sometimes referred to as Pretest) to determine the preparation levels of entering advanced practice nursing (APN) students. The Pretest provided information regarding nursing students’ geriatric knowledge.
Description of Geriatric Knowledge Self-Assessment Tool The above-cited Essentials of Baccalaureate Education for Professional Nursing Practice guided the formulation of 12 objectives addressed in 50 self-assessment questions (see Table 1 for the list of objectives). Dr. Meg Walhagen, geriatric nurse practitioner, project consultant, and content expert, created this list of objectives.
Journal of Professional Nursing, Vol 22, No 2 (March–April), 2006: pp 112– 115 A 2006 Elsevier Inc. All rights reserved.
ASSESSMENT OF GERIATRIC KNOWLEDGE
Table 1. Objectives for the Self-Assessment of Geriatric Knowledge Students Should Be Able To: (1) Understand current and projected demographic characteristics of the older population (z65 years) and their relationship with the health care system and nursing practice. (2) Identify myths of aging and their impact on the care provided to older adults and their families. (3) Differentiate between common normal changes and pathologic changes. (4) Describe the goals of health care of the elderly, based on their special needs. (5) Recognize how changes that occur with age influence the presentation of acute and chronic problems, as well as their response to various treatment modalities. (6) Identify risk factors and measures used for prevention that are important for the care of older adults. (7) Identify established tools that are used to assess the functional status (physical, cognitive, and psychosocial) of older adults. (8) Recognize common geriatric syndromes and delineate approaches to their management (i.e., falls, incontinence, iatrogenesis, polypharmacy, dementia, and delirium). (9) Delineate the role of family and friends in providing care to community-dwelling elders. (10) Adapt teaching strategies to the needs of older adults based on an understanding of physical, cognitive, and psychosocial changes that occur with age. (11) Describe how health care policies and the current health care system influence access to resources and care decisions. (12) Define and differentiate approaches to delineating the health care wishes of older adults.
The self-assessment test addresses basic knowledge and skills necessary for the generalist nurse to provide competent geriatric health care; it is not a comprehensive summary of skills needed by a geriatric nurse specialist. Test questions address the recommended objectives and endeavor to prescribe a compliment of geriatric competencies needed by participating students, with varying depths for each targeted idea. Some objectives are incorporated into as many as nine questions, whereas others require fewer questions. For instance, Objective 5: bRecognize how changes that occur with aging influence the presentation of acute and chronic problems and responses to treatmentsQ spreads itself out among the greatest number of questions. The Self-Assessment of Geriatric Knowledge is selfadministered online and may be completed on any personal computer (PC). Test results are sent to each student immediately, as well as to the faculty. Examples of questions, as presented in the test, are shown in Table 2. Test results show the correct answer and the student’s answer, as well as the individual’s overall score. A student receives, per incorrect answer, online references that may be accessed instantly by clicking on the reference links. The sources of these references include
113
the Gerontological Nursing Certification Review Course of the John A. Hartford Foundation for Geriatric Nursing (n.d.), The Merck Manual of Geriatrics (n.d.), and other professional online resources. These references, linked to individual questions, provide the students with immediate remedial opportunities. The process of test completion is relatively uncomplicated: (1) The responsible faculty member registers a group of students at www.geriatriceducation.org; (2) a password is received online; (3) then, students may log in from any PC, complete the 50 item test, and receive immediate results. The registering faculty member also receives the results. Such data are designed to provide useful information to faculty members who plan to incorporate geriatric content into their curriculum.
Self-Assessment Test Participants and Results All family nurse practitioner students entering the Western University College of Graduate Nursing between 2001 and 2003 (the period of data collection) completed the Pretest. During those 3 years, graduate nursing students from eight other university nursing programs also completed the self-assessment test, with 158 APN students participating. The faculty from these eight programs volunteered to test their students in response to information provided through the Hartford Geriatric Nursing Initiative listserve. Participant data show that 49% were over 40 years old, and 60% had more than 5 years of nursing experience. These data indicate that approximately half of this group of students entering APN programs may have completed a Bachelor of Science in Nursing (BSN) several years prior to graduate school enrollment. These students were at risk for limited preparation in geriatric principles, as noted by Fulmer and Matzo in their study of nursing curricula, as cited in AACN and Hartford (2000).
Table 2. Examples of Pretest Questions (1) Which of the following statements most accurately describes the U.S. population 65 years old and above? o (A) The majority of older adults (65 years and older) are female. o (B) In the past 10 years, the number of individuals over 85 years has been declining. o (C) African American women outlive their Caucasian counterparts by 3–5 years. o (D) More than 35% of persons over 80 years are in nursing homes at any given time. o (E) A and C (2) In terms of the total population, the most rapidly growing segment of the population in the United States is the segment: o (A) Between the ages of 65 and 70 years o (B) Between the ages of 70 and 75 years o (C) Between the ages of 75 and 80 years o (D) Between the ages of 80 and 85 years o (E) 85 years and older
114
ELIZABETH M. TOWNER
Figure 1.
Comparison of mean scores, by objective and total mean score.
Self-assessment test results are reported as total scores and according to test objectives to describe competencies in each content area. Mean total scores varied from 51% to 54% for the group of 158 test takers over the 3 years. Scores compiled for each of the 12 objectives showed noteworthy differences. Results are reported by percentages due to differences in the numbers of questions for each objective, as described above. Figure 1 shows comparisons of the 12 objectives. This graph compares the mean scores of each objective in tests completed by students from five programs from June to August 2003. Results from previous test takers were similar. The 2003 mean scores (n = 63) indicated an understanding of teaching strategies (M = 94% correct), of goals of the health care of the elderly (M = 74% correct), and the presentation of symptoms in the aged and their responses to medications (M = 64% correct). Lower mean scores were clustered for these five objectives: normal age changes versus pathological changes (58%); recognizing geriatric syndromes (58%); tools to assess functional status (55%); carrying out health care wishes (54%); and myths of aging (52%). Results also showed some important aspects of geriatric health care with mean scores of less than 50%: prevention strategies and risk assessment (49%) and role assumption for the care of elders in the community (46%). Demographic data in the United States (35%) and knowledge of services by the health
care system for the elderly (35%) displayed the lowest mean scores for these test takers. Interestingly, no significant differences in mean scores were seen in these subjects when compared by age, academic degree, or work setting experience. In addition, scores were examined relative to nursing experience, geriatric nursing experience, and completion of geriatric course. No significant differences were shown.
Conclusions Conclusions from this test analysis should be related only to this group of participants. These data represent a preliminary description of BSN graduates’ geriatric competency, from which no generalizations can be generated. These levels of mean score, both overall means and means for individual objectives, demonstrate a need for expanded geriatric content in BSN education. These participants had the greatest deficits in the following areas: myths of aging, prevention strategies and risk factors, roles and responsibilities for the care of elderly persons in the community, health policies that affect elder care, and demographic data of our geriatric population. Clearly, the BSN curriculum should not only increase student knowledge about the direct treatment of elders, but should also increase student awareness of elder health care’s political and social context.
ASSESSMENT OF GERIATRIC KNOWLEDGE
Recommendations The test tool should be evaluated by faculty members for reliability and validity by increasing the number and variety of test takers over time and by continually scrutinizing the breadth of content being examined. These data suggest the need for systematic assessment and enhancement of BSN geriatric content. Neither the Self-Assessment of Geriatric Knowledge nor the results from these 158 test takers are meant to be conclusive, but they do provide an exploration of the varied gerontology nursing knowledge levels of entering graduate students. These project results contribute to faculty awareness of curricular needs— to prepare students for competent geriatric nursing care of the growing older population. The Self-Assessment of Geriatric Knowledge, with further development and evaluation, may assist the faculty in assessing the gerontological nursing competencies of BSN graduates for the next several years. Significantly improved test scores will indicate sufficient and appropriate expansion of geriatric content in BSN curricula. The Self-Assessment of Geriatric Knowledge could also be considered for
115
precourse and postcourse assessments for curriculum evaluation and for the assessment of a geriatric nurse’s preparation.
References Agency on Aging. (2000). Older Americans 2000: Key indicators of wellbeing: Federal interagency forum on agingrelated statistics. Retrieved on July 11, 2005 from http:// agingstats.gov/chartbook2000/population.html. American Association of Colleges of Nursing [AACN]. (1998). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing [AACN], & The John A. Hartford Foundation Institute for Geriatric Nursing [Hartford]. (2000). Older adults: Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care. Retrieved July 11, 2005, from www.aacn.nch. edu/Education/gercomp. John A. Hartford Foundation for Geriatric Nursing. (2004). Gerontological nursing certification review course. Retrieved July 11, 2005, from http://education.nyu.edu/nursing/ hartford.institute/course/. The Merck manual of geriatrics (3rd ed.). Retrieved July 11, 2005, from www.merckbooks.com/mgeri/.