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Ensuring a knowledgeable and committed gerontological nursing workforce
Nurse Education Today (2007) 27, 113–121
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Ensuring a knowledgeable and committed gerontological nursing workforce Donna J. Plonczynski *, Linda Ehrlich-Jones, Julie Fisher Robertson, Jeanette Rossetti, Donna J. Munroe, Mary Elaine Koren, Georgine Berent, Judith Hertz Northern Illinois University, 1240 Normal Road, DeKalb, IL 60115, United States Accepted 5 April 2006
KEYWORDS
Summary There is a growing societal need for professional nurses who are knowledgeable and committed to working with older adults. In order to address this need, a small study that included self-evaluation and curriculum review was conducted by faculty at one Midwestern nursing program in the United States. A moderately positive attitude, moderately high knowledge, and moderate pursuit of knowledge of older adults were identified with the faculty in the presence of limited curricular content of gerontology. Implications for nursing education included continuing education for nursing faculty and program support in nursing curricula. c 2006 Elsevier Ltd. All rights reserved.
Gerontology; Faculty; Nursing; Curriculum
Introduction
In the year 2002, there were an estimated 36 million Americans 65 years of age or older (US Census Bureau, 2000). It is projected that by the year 2030, this group will double to 70 million, while the worldwide population of older adults is projected to increase by 550 million to 973 million (CDC, 2005). Across the world, developed and developing countries are facing aging issues (Commission of the European Communities, 2002). * Corresponding author. Tel.: +1 815 753 6584; fax: +1 815 753 0814. E-mail address: [email protected] (D.J. Plonczynski).
The significance to the health care system is that older adults have poorer health and require more health care services than younger adults, and more than 90% of older adults have at least one chronic illness (Huffman et al., 1996). These health needs require skilled assessment, case management, and access to acute hospital, rehabilitation and community care (Happell and Brooker, 2001). Specifically, older adults account for 50% of hospitalized clients, 85% of home care clients, and more than 90% of nursing home residents (Bednash et al., 2003). As a result of this societal evolution, there is an increasing need for professional nurses who are knowledgeable and committed to working with
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.04.004
114 the older adult population in diverse settings. Nursing must be poised to address the increasing gerontological population (Burggraf and Barry, 1998; Mezey and Fulmer, 2002). Newly licensed nurses can expect to deliver healthcare frequently to older adults as they make up 62.5% of their patient caseload (Wendt, 2003). This increased societal need is occurring in the midst of a shortage of nurses, those specially trained in gerontology, and nursing faculty; all of which provides the structure for an upcoming crisis in healthcare. The nursing shortage is predicted by 2010 to include more than one million vacant professional nursing positions (Hecker, 2001). Fewer young adults are choosing nursing as a career due to an expanded array of options now available to women (Auerbach et al., 2000). This nursing shortage is characterized by fewer nurses entering the workforce, as well as shortages of nurses adequately prepared to meet specific areas of patient need (Thornlow et al., 2006). Not only is there a need for a greater number of nurses, but for more nurses well versed in the care of older adults (Kovner et al., 2002). Compounding the nursing shortage is the parallel shortage of nursing faculty. Experienced nurses to teach the next generations of nurses are decreasing in members and reaching retirement age, while fewer nurses are choosing to teach within their profession. This critical shortage is now present and not expected to recede soon (Hollinger-Smith, 2003). In order to prepare the next generations of nurses for the aging revolution, it is first necessary to evaluate the current faculty member’s attitudes, knowledge, learning needs, as well as the program’s curricular needs in gerontology. While acknowledging higher societal needs, and decreasing faculty to address these needs, the first step in progressing the agenda of better healthcare for older adults is the building of nursing faculty acumen (Hanson and Waters, 1992; Hollinger-Smith, 2003).
Purpose The purpose of this research was the evaluation of the faculty member’s gerontological strengths and needs, concurrent with the evaluation of the curriculum on gerontological content in one Midwestern nursing program. The following four questions were answered: 1. What are the faculty’s attitudes regarding older adults? 2. What is the gerontological knowledge level of the faculty?
D.J. Plonczynski et al. 3. What are the learning needs of faculty regarding gerontological nursing? 4. What gerontological content is included in the curriculum?
Theoretical framework and literature review This study forms part of a wider participatory action research (PAR) project which was used as the conceptual framework (Merriam and Simpson, 2000; Park, 1999). This theory frames the process by which the group defines and solves identified problems. This theory was originally developed to empower group members to engage in a process in order facilitate change and to apply the findings in developing policies and programs. Participatory action research has been used by nurse researchers in developing and discovering interventions (Duffy et al., 2003; Griffiths, 1999; Parker et al., 2000), however here we report principally the findings of a survey of faculty attitudes to older people. Historically, some nurses held negative attitudes about gerontological care when compared to other patient groups in healthcare (Philpose et al., 1991). Caring for the older adult has been devalued due to the perception that it requires less skill and knowledge (Mahoney, 1993). This attitude transferred across nursing fields, as faculty members have been found to identify a lack of need or importance to gerontological nursing (Newbern and Kennedy-Malone, 1994). Fortunately, numerous studies demonstrate that further education in gerontology improved attitudes toward older adults (Damron-Rodriguez et al., 1998; Fowler, 1997; Newbern and Kennedy-Malone, 1994; Sheffler, 1998; Shoemake et al., 1998; So ¨derhamn et al., 2001). In addition to changing negative attitudes, faculty knowledge of gerontology provides for the transfer to students positive attitudes, in addition to further knowledge (Yurchuck and Kee, 1991). High levels of knowledge by faculty have been found to translate into quality mentors for nursing students (Verderber, 1990). Feldman’s (1988) analysis of 18 research studies identified the teacher’s knowledge of the subject as one of the important instructional dimensions to students. Not surprisingly, higher levels of knowledge of gerontology were reported by faculty who taught the topic, when compared to those who taught other nursing courses (Ryden and Johnson, 1992). Unfortunately, there are low numbers of nurses who have obtained advanced credentials as gerontological nurses
Ensuring a knowledgeable and committed gerontological nursing workforce (Rosenfeld et al., 1999) and faculty with minimal background often teach courses in gerontology (Bahr, 1987). Faculty with little or no preparation in gerontology may compound their knowledge gap by promoting inappropriate attitudes and values in their students (Bahr, 1987). Knowledge and the ongoing search for knowledge is a common prerequisite to being a good teacher in higher education. In a study by Rossetti (2002), outstanding professors were noted to not only promote their students learning, but also pursued their own ongoing learning. Keeping up with the ever-changing developments in their respective fields was a recurrent theme noted in this qualitative study. The professors stressed the importance of keeping current and remaining on the cutting edge. Multiple topics of ongoing educational needs are identified from studies in the literature. These topics include theories of aging and the aging processes, assessment methods, common health problems, legal/ethical issues including regulatory and reimbursement issues, health teaching methods with older adults, current nursing research findings in gerontology, and environmental issues for older adults (Chon et al., 2002; Costello et al., 1999; Joy et al., 2000; Wendt, 2003). There is limited information on the percentage of gerontological content in nursing curricula throughout the country because it tends to be embedded in courses. A recent national survey of baccalaureate nursing education found less than one-fourth of the programs required a nursing course devoted to gerontology and only half of the programs required some type of clinical experience in a long-term care setting (Rosenfeld et al., 1999). This paucity of gerontology content has resulted in few experts in this growing field, and thus has resulted in the renewed interest in the implementation of gerontology into nursing education and clinical experiences (Thornlow et al., 2006; American Association of Colleges of Nursing and Nursing, 2000; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing (Hartford), 2000; Milisen et al., 2004).
Methods
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Instruments Three instruments were used in data collection: the AGED inventory, Nursing Course Assessment, and Faculty Needs Assessment. The AGED inventory is comprised of 28 adjective pairs that are evaluative of the respondent’s attitudes and stereotypes of different age groups. Respondents choose on a seven-point scale between two opposing adjectives with one representing most negative to seven representing most positive. Fourteen of the 28 adjective pairs were reverse scored. The 28 factors are grouped into four dimensions with the following reported reliability scores: positiveness r = 0.57 (0.48–0.63); vitality r = 0.75 (0.57–0.84); goodness r = 0.72 (0.61–0.75); maturity r = 0.73 (0.59–0.77). Validity of the AGED inventory has been confirmed through factor analysis leading to evaluative and descriptive subscales composed of four dimensions. Goodness and positiveness comprise the evaluative subscale while vitality and maturity constitute the descriptive subscale (Knox et al., 1995). For this study, a score of one-to-three was coded as a positive attribute, a score of four was considered neutral, and scores higher than four were coded as a negative perception. Cronbach’s alpha was calculated at 0.98 for the AGED Inventory for this study. Both the Nursing Course Assessment and Faculty Needs Assessment instruments were developed specifically for this research. Content validity was established by expert faculty evaluation. The Nursing Course Assessment consists of six questions used to assess the gerontological content of each undergraduate course. The course assessment instrument measures the percentage of gerontological content, number of hours per semester of gerontological content as well as teaching strategies for each nursing course. The Faculty Needs Assessment consists of three questions where faculty rate their overall gerontological knowledge on a scale of zero-to-nine. The faculty was also asked to indicate as many gerontological topics that were of interest from a list of 15 and a space allowed for additional choices. The list was developed from the required core competencies that were developed jointly by the AACN and the Hartford Foundation (2000).
Design
Procedure
This cross-sectional research design included volunteer subject faculty from one Midwestern school of nursing. The data collection occurred during a curriculum review day.
After IRB approval was obtained, all faculty members were solicited to participate in the study. The purpose of the study was explained, and interested faculty signed a consent form and completed
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Results Data analysis was performed through SPSS v. 11. Internal reliability assessment by Cronbach’s alpha was completed for the AGED inventory. Descriptive statistics, Student t-test, and correlations were used to analyze data. Twenty-six faculty members participated in the study. They were all Caucasian women living in the areas across a large midwestern United States city vicinity, including the more rural communities near the University setting.
84
Percentage of respondents
the three questionnaires. The questionnaires required 30–45 min to finish.
82. 6
82. 6
Percent
82 80
78. 3
78. 3
78 76
73. 9
73. 9
74 72 70 68
st
ne
Ho
e
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nc
Si
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cia
So
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gn Di
Attributes
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Figure 1 Most commonly identified positive attributes of older adults.
Attitudes toward older adults The most commonly identified attributes of older adults on the AGED Inventory were: honest (83%), sincere (83%), social (78%), dignified (78%), considerate (74%), and productive (74%) (Fig. 1). Student t-testing compared the positively coded attributes and those coded neutrally or negatively. The analysis showed an even distribution of the faculty’s attitudes toward older adults. Fourteen of the 28 attributes were coded by the faculty positively, compared to 14 coded either neutrally or negatively. There was a non-significant Student t-test between the positively coded responses when compared to the neutral/negative responses (t = 1.23 [df = 22], p = 0.23). Faculty attitudes were equivalently divided between positive and the neutral/ negative attitudes.
Faculty pursuit of knowledge and topics of interest A mean score of 6.58 (SD: 1.58; range 2–8 of 0–9 possible) was found from faculty knowledge of gerontological issues. Faculty’s pursuit of gerontological knowledge mean was 3.32 (SD: 1.49; range 1–5 of 1–5 possible). The most common topics of interest in gerontology were insurance (31%), physiology of aging (31%), community resources (27%), and elder abuse (27%) (Fig. 2). In addition, 23% of the faculty listed caregiver strain, end of life issues, spirituality and specific disease conditions as areas of educational need. Faculty knowledge was significantly related to pursuit of knowledge with r = 0.54, F(1,22) = 8.85, p = 0.007.
35
Percentage of Respondants
31
Percent
31
30
27
27
25 20 15 10 5 0
Physiology of Aging
Insurance
Elder Abuse
Community Resources
Topics of Gerontology interest
Figure 2
Topics of interest for continuing gerontology knowledge.
Ensuring a knowledgeable and committed gerontological nursing workforce
51- 75%
117
>76%
26- 50% <5 %
5- 25%
Figure 3 Gerontological content in master syllabi. Note. Starting at top right, first slice represents 44% of total numbers of courses surveyed, followed clockwise with 34%, 11%, 6%, and 5%.
Dissemination of gerontological information Faculty rated the majority of courses (44%) to have less than five percent of gerontological content in the master syllabi in courses they taught in the previous year. Thirty-four percent of courses were rated at having 5–25% gerontological content in their syllabi, while 11% had 25–50%, 6% had 51– 75% and 5% had 76–100% gerontological content in the master syllabi. Higher percentages of gerontological content are found in few courses as depicted in Fig. 3.
Discussion Results: attitudes toward older adults Three of the most common attributes chosen by the faculty fell into the goodness dimension of the AGED Inventory (honest, sincere, and considerate), while two items, sociable and productive fell into the positiveness dimension. Additional attributes chosen by the majority of faculty include generous and wise (goodness dimension) and involved (positiveness dimension). All these attributes have been judged to be evaluative and serve as a good report of attitudes (Knox et al., 1995). One attribute, active, was chosen by the faculty and is characterized as a vitality item. Another item, dignified, was chosen by 78.3% of the faculty and it is characterized as a maturity item. These two attributes are judged as descriptive items. They are better utilized in assessing the degree of age stereotypes (Knox et al., 1995). Overall, the faculty had moderately positive attitudes toward older adults. The attitudes expressed by this faculty group are somewhat less positive than those in the literature. MacDowell et al. (1999) reported that women and college graduates
had more positive attitudes about the elderly. Fowler (1997) found that practicing healthcare professionals (radiographers) had positive attitudes about the elderly, and transferred these attitudes to their students.
Results: knowledge The faculty in this study affirms the findings in the literature in that individuals as they grow older demonstrate more knowledge about the elderly (MacDowell et al., 1999; Sherman et al., 1996). Sherman and colleagues also found that those with graduate degrees had higher knowledge scores about older adults. Topics with which faculty are most knowledgeable include normal aging and common health problems, both of which have been previously identified (Yurchuck and Kee, 1991).
Results: faculty pursuit of knowledge This study found that those faculty who had more knowledge continued to pursue more knowledge. In a study by Ryden and Johnson (1992) faculty knowledge of gerontology was found to be highly related to their current professional growth interests. This indicates that faculty with specific knowledge pursues more information in their field. Although improvements in faculty access to gerontological continuing education have occurred, there historically have been limited programs to address faculty development in gerontology (Tyson, 1992). The continuing pursuit of knowledge in a subject is a common prerequisite to being a good teacher in higher education (Rossetti, 2002).
Results: topics of interest The highest rated topic areas were: community resources, elder abuse, insurance, and physiology of
118 aging. All of these topics relate to AACN and Hartford recommendations (2000). Gerontology topics listed as most important for professional development in the field over a decade ago were assessment, health promotion, ethics, coping with chronic disease, and pharmacology (Ryden and Johnson, 1992). This difference seen across time is likely related to the changes that have occurred in the previous decade (Lawler, 1995). Basic knowledge and skills were not topics well established in gerontological nursing a decade ago as they are now. Healthcare has moved to the community, with the emerging questions of caregiver burnout and elder abuse.
Results: percent gerontology in curriculum The majority of nursing courses examined contained less than 5% of gerontological nursing content. There is no stand-alone nursing course dealing with gerontological nursing in the curriculum. This integration of gerontology curriculum is consistent with nursing education philosophy (Rosenfeld et al., 1999). However, it has been identified that in order to meet current needs of an aging society, more gerontological nursing content is merited across countries (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004).
Implications: faculty Major trends in healthcare demand changes in program development in nursing (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004) and these changes must start with the nursing faculty (Hanson and Waters, 1992). Faculty have the obligation to prepare the next generation to be knowledgeable in gerontology, and this knowledge has been found in the literature to improve attitudes (Yurchuck and Kee, 1991), thereby providing a committed workforce as well. In order to meet the growing worldwide need, competent faculty are needed (Baumbusch and Goldenberg, 2000). This study found moderately high faculty knowledge and moderate levels of pursuit of knowledge in gerontology. Methods to address further educational opportunities for faculty in gerontology are indicated. Many nursing faculty worldwide had undertaken nursing education at a time when little focus was placed on gerontology (Joy et al., 2000). In order to meet the needs of faculty, it is impera-
D.J. Plonczynski et al. tive that the learning experience has value. Value on the learning experience may be facilitated by problem solving involvement, evidence for the need and value of this information, and exposure to positive experiences (Letvak, 2002). Students are aware that a majority of their patient caseload will include older adults. However, little information is available about students who are attracted to gerontological nursing. The insufficient number of faculty with graduate preparation and experience in gerontological nursing contribute to the lack of interest nursing students have about careers in long term care (HollingerSmith, 2003). Current registered nurses and faculty need to look to continuing education for furthering their gerontological knowledge (Denton, 1990; Milisen et al., 2004).
Implications: curriculum Refining curriculum for increasing gerontological content is seen as the most challenging component of the educational process (Yurchuck and Kee, 1991). In their comprehensive national study, Rosenfeld and colleagues (1999) investigated the prevalence of methods used to teach gerontology to nursing students. The majority of programs integrated gerontological content into the overall curriculum (63%). Hirst and Metcalf (1989) compared the advantages and disadvantages of gerontological content integration vs. segregation in nursing curriculum. They suggested that integration is easier and more efficient, but noted that both models require faculty expertise in gerontology. In the integrated model, faculty needs support regarding the appropriate type, amount and degree of emphasis on gerontology content. In the segregated model, faculty expertise is needed to teach the courses. A multidisciplinary approach to meeting the needs of older individuals has been suggested along with collaborative work with aged care settings, services and organizations (Joy et al., 2000). Researchers (Rosenfeld et al., 1999) also inquired about barriers to incorporating gerontological content in the baccalaureate curriculum. Sixty-six percent of respondents reported overloaded curriculum and over half reported a lack of qualified full-time or part-time faculty members as ‘‘somewhat’’ or ‘‘significant’’ barriers. More than 60% of these programs reported a need for assistance with faculty development and curriculum materials, such as written materials, interactive material on the Internet and computer assisted instruction, to strengthen the gerontological nursing preparation of their students.
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National and international committees have identified the growing need to prepare nursing faculty with the knowledge and expertise in gerontology to teach pre-licensure nursing students (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004). Enhancing the knowledge and skills of pre-licensure nursing students requires first, an emphasis on faculty, followed by curriculum enhancement. Experiences in nursing education suggest that assigning specific faculty to teach the same courses all the time is unrealistic because of the limited faculty resources faced by many nursing programs (Hinshaw, 2001). Changes in curriculum may sustain ongoing learning in gerontology in nursing even when faculty change.
Limitations
Implementation
Conclusion
Plans to address the educational needs of the faculty in this study are underway. Providing faculty with knowledge about gerontology is expected to lead to more positive attitudes toward older adults, as identified in the literature. Curricular changes need to be addressed in order to provide students with the information they need to become knowledgeable and committed nurses to the increasing population of older adults.
Due to the changing population demographics, there is a growing worldwide need for professional nurses who are knowledgeable and committed to working with older adults in diverse settings. The main purpose of this study was to determine the needs of faculty and the curricula at a state university nursing program in the midwestern United States. The findings supported a moderately positive attitude of the faculty toward older adults, a moderately high level of faculty gerontology knowledge, and active pursuit of knowledge for those with higher levels of knowledge in gerontology. While teaching gerontology content to nursing students throughout the curriculum, this faculty readily identified the need for more information and resources related to important health and caregiver issues for older persons.While there is an overall awareness of the policy and service concerns of older persons and their families, these faculty members see the need to further enhance knowledge to provide the most current and best practices to the nursing providers of the future. The first step in this knowledge acquisition is to address the faculty learning needs and adjust the curriculum to reflect core content. Making this step, begins the process of meeting the larger societal need for knowledgeable and committed gerontologically savvy nurses.
Future research Research is underway to assess the perceptions of the faculty in regards to how the curricula addresses the needs of the older adult as well as the facilitators and barriers to increasing geriatric content into the curriculum. These answers could assist with the development of changes in the curriculum. In addition, assessment of the knowledge and attitudes of the nursing students is planned. Replication of this research at other institutions could assist in the determination of trends in nursing education and the need for standardized curricular changes.
Theory application According to Bogdan and Bilken (1998), it is imperative to receive input from the ‘‘real world’’ or the ‘‘real participants’’ of any research study. The evaluation process was adopted to provide each faculty participant with a voice in the identification of their own gerontological attitudes, knowledge, needs, as well as curricular content.
Although similar to nursing faculty across the United States (Merriam and Caffarella, 1999), the faculty in this study was predominantly Caucasian women with limited cultural variability. In addition, the small sample size makes it difficult to generalize these data to other groups particularly when an advantage of questionnaires is that they can be administered, and have greater power, when used in large numbers. The cross-sectional design looked at the data at one point in time. Assessing the attitudes and gerontological knowledge of faculty over time would give a more reliable look at what interventions would be most beneficial in producing change.
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
Ensuring a knowledgeable and committed gerontological nursing workforce Donna J. Plonczynski *, Linda Ehrlich-Jones, Julie Fisher Robertson, Jeanette Rossetti, Donna J. Munroe, Mary Elaine Koren, Georgine Berent, Judith Hertz Northern Illinois University, 1240 Normal Road, DeKalb, IL 60115, United States Accepted 5 April 2006
KEYWORDS
Summary There is a growing societal need for professional nurses who are knowledgeable and committed to working with older adults. In order to address this need, a small study that included self-evaluation and curriculum review was conducted by faculty at one Midwestern nursing program in the United States. A moderately positive attitude, moderately high knowledge, and moderate pursuit of knowledge of older adults were identified with the faculty in the presence of limited curricular content of gerontology. Implications for nursing education included continuing education for nursing faculty and program support in nursing curricula. c 2006 Elsevier Ltd. All rights reserved.
Gerontology; Faculty; Nursing; Curriculum
Introduction
In the year 2002, there were an estimated 36 million Americans 65 years of age or older (US Census Bureau, 2000). It is projected that by the year 2030, this group will double to 70 million, while the worldwide population of older adults is projected to increase by 550 million to 973 million (CDC, 2005). Across the world, developed and developing countries are facing aging issues (Commission of the European Communities, 2002). * Corresponding author. Tel.: +1 815 753 6584; fax: +1 815 753 0814. E-mail address: [email protected] (D.J. Plonczynski).
The significance to the health care system is that older adults have poorer health and require more health care services than younger adults, and more than 90% of older adults have at least one chronic illness (Huffman et al., 1996). These health needs require skilled assessment, case management, and access to acute hospital, rehabilitation and community care (Happell and Brooker, 2001). Specifically, older adults account for 50% of hospitalized clients, 85% of home care clients, and more than 90% of nursing home residents (Bednash et al., 2003). As a result of this societal evolution, there is an increasing need for professional nurses who are knowledgeable and committed to working with
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114 the older adult population in diverse settings. Nursing must be poised to address the increasing gerontological population (Burggraf and Barry, 1998; Mezey and Fulmer, 2002). Newly licensed nurses can expect to deliver healthcare frequently to older adults as they make up 62.5% of their patient caseload (Wendt, 2003). This increased societal need is occurring in the midst of a shortage of nurses, those specially trained in gerontology, and nursing faculty; all of which provides the structure for an upcoming crisis in healthcare. The nursing shortage is predicted by 2010 to include more than one million vacant professional nursing positions (Hecker, 2001). Fewer young adults are choosing nursing as a career due to an expanded array of options now available to women (Auerbach et al., 2000). This nursing shortage is characterized by fewer nurses entering the workforce, as well as shortages of nurses adequately prepared to meet specific areas of patient need (Thornlow et al., 2006). Not only is there a need for a greater number of nurses, but for more nurses well versed in the care of older adults (Kovner et al., 2002). Compounding the nursing shortage is the parallel shortage of nursing faculty. Experienced nurses to teach the next generations of nurses are decreasing in members and reaching retirement age, while fewer nurses are choosing to teach within their profession. This critical shortage is now present and not expected to recede soon (Hollinger-Smith, 2003). In order to prepare the next generations of nurses for the aging revolution, it is first necessary to evaluate the current faculty member’s attitudes, knowledge, learning needs, as well as the program’s curricular needs in gerontology. While acknowledging higher societal needs, and decreasing faculty to address these needs, the first step in progressing the agenda of better healthcare for older adults is the building of nursing faculty acumen (Hanson and Waters, 1992; Hollinger-Smith, 2003).
Purpose The purpose of this research was the evaluation of the faculty member’s gerontological strengths and needs, concurrent with the evaluation of the curriculum on gerontological content in one Midwestern nursing program. The following four questions were answered: 1. What are the faculty’s attitudes regarding older adults? 2. What is the gerontological knowledge level of the faculty?
D.J. Plonczynski et al. 3. What are the learning needs of faculty regarding gerontological nursing? 4. What gerontological content is included in the curriculum?
Theoretical framework and literature review This study forms part of a wider participatory action research (PAR) project which was used as the conceptual framework (Merriam and Simpson, 2000; Park, 1999). This theory frames the process by which the group defines and solves identified problems. This theory was originally developed to empower group members to engage in a process in order facilitate change and to apply the findings in developing policies and programs. Participatory action research has been used by nurse researchers in developing and discovering interventions (Duffy et al., 2003; Griffiths, 1999; Parker et al., 2000), however here we report principally the findings of a survey of faculty attitudes to older people. Historically, some nurses held negative attitudes about gerontological care when compared to other patient groups in healthcare (Philpose et al., 1991). Caring for the older adult has been devalued due to the perception that it requires less skill and knowledge (Mahoney, 1993). This attitude transferred across nursing fields, as faculty members have been found to identify a lack of need or importance to gerontological nursing (Newbern and Kennedy-Malone, 1994). Fortunately, numerous studies demonstrate that further education in gerontology improved attitudes toward older adults (Damron-Rodriguez et al., 1998; Fowler, 1997; Newbern and Kennedy-Malone, 1994; Sheffler, 1998; Shoemake et al., 1998; So ¨derhamn et al., 2001). In addition to changing negative attitudes, faculty knowledge of gerontology provides for the transfer to students positive attitudes, in addition to further knowledge (Yurchuck and Kee, 1991). High levels of knowledge by faculty have been found to translate into quality mentors for nursing students (Verderber, 1990). Feldman’s (1988) analysis of 18 research studies identified the teacher’s knowledge of the subject as one of the important instructional dimensions to students. Not surprisingly, higher levels of knowledge of gerontology were reported by faculty who taught the topic, when compared to those who taught other nursing courses (Ryden and Johnson, 1992). Unfortunately, there are low numbers of nurses who have obtained advanced credentials as gerontological nurses
Ensuring a knowledgeable and committed gerontological nursing workforce (Rosenfeld et al., 1999) and faculty with minimal background often teach courses in gerontology (Bahr, 1987). Faculty with little or no preparation in gerontology may compound their knowledge gap by promoting inappropriate attitudes and values in their students (Bahr, 1987). Knowledge and the ongoing search for knowledge is a common prerequisite to being a good teacher in higher education. In a study by Rossetti (2002), outstanding professors were noted to not only promote their students learning, but also pursued their own ongoing learning. Keeping up with the ever-changing developments in their respective fields was a recurrent theme noted in this qualitative study. The professors stressed the importance of keeping current and remaining on the cutting edge. Multiple topics of ongoing educational needs are identified from studies in the literature. These topics include theories of aging and the aging processes, assessment methods, common health problems, legal/ethical issues including regulatory and reimbursement issues, health teaching methods with older adults, current nursing research findings in gerontology, and environmental issues for older adults (Chon et al., 2002; Costello et al., 1999; Joy et al., 2000; Wendt, 2003). There is limited information on the percentage of gerontological content in nursing curricula throughout the country because it tends to be embedded in courses. A recent national survey of baccalaureate nursing education found less than one-fourth of the programs required a nursing course devoted to gerontology and only half of the programs required some type of clinical experience in a long-term care setting (Rosenfeld et al., 1999). This paucity of gerontology content has resulted in few experts in this growing field, and thus has resulted in the renewed interest in the implementation of gerontology into nursing education and clinical experiences (Thornlow et al., 2006; American Association of Colleges of Nursing and Nursing, 2000; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing (Hartford), 2000; Milisen et al., 2004).
Methods
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Instruments Three instruments were used in data collection: the AGED inventory, Nursing Course Assessment, and Faculty Needs Assessment. The AGED inventory is comprised of 28 adjective pairs that are evaluative of the respondent’s attitudes and stereotypes of different age groups. Respondents choose on a seven-point scale between two opposing adjectives with one representing most negative to seven representing most positive. Fourteen of the 28 adjective pairs were reverse scored. The 28 factors are grouped into four dimensions with the following reported reliability scores: positiveness r = 0.57 (0.48–0.63); vitality r = 0.75 (0.57–0.84); goodness r = 0.72 (0.61–0.75); maturity r = 0.73 (0.59–0.77). Validity of the AGED inventory has been confirmed through factor analysis leading to evaluative and descriptive subscales composed of four dimensions. Goodness and positiveness comprise the evaluative subscale while vitality and maturity constitute the descriptive subscale (Knox et al., 1995). For this study, a score of one-to-three was coded as a positive attribute, a score of four was considered neutral, and scores higher than four were coded as a negative perception. Cronbach’s alpha was calculated at 0.98 for the AGED Inventory for this study. Both the Nursing Course Assessment and Faculty Needs Assessment instruments were developed specifically for this research. Content validity was established by expert faculty evaluation. The Nursing Course Assessment consists of six questions used to assess the gerontological content of each undergraduate course. The course assessment instrument measures the percentage of gerontological content, number of hours per semester of gerontological content as well as teaching strategies for each nursing course. The Faculty Needs Assessment consists of three questions where faculty rate their overall gerontological knowledge on a scale of zero-to-nine. The faculty was also asked to indicate as many gerontological topics that were of interest from a list of 15 and a space allowed for additional choices. The list was developed from the required core competencies that were developed jointly by the AACN and the Hartford Foundation (2000).
Design
Procedure
This cross-sectional research design included volunteer subject faculty from one Midwestern school of nursing. The data collection occurred during a curriculum review day.
After IRB approval was obtained, all faculty members were solicited to participate in the study. The purpose of the study was explained, and interested faculty signed a consent form and completed
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Results Data analysis was performed through SPSS v. 11. Internal reliability assessment by Cronbach’s alpha was completed for the AGED inventory. Descriptive statistics, Student t-test, and correlations were used to analyze data. Twenty-six faculty members participated in the study. They were all Caucasian women living in the areas across a large midwestern United States city vicinity, including the more rural communities near the University setting.
84
Percentage of respondents
the three questionnaires. The questionnaires required 30–45 min to finish.
82. 6
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Percent
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78 76
73. 9
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Figure 1 Most commonly identified positive attributes of older adults.
Attitudes toward older adults The most commonly identified attributes of older adults on the AGED Inventory were: honest (83%), sincere (83%), social (78%), dignified (78%), considerate (74%), and productive (74%) (Fig. 1). Student t-testing compared the positively coded attributes and those coded neutrally or negatively. The analysis showed an even distribution of the faculty’s attitudes toward older adults. Fourteen of the 28 attributes were coded by the faculty positively, compared to 14 coded either neutrally or negatively. There was a non-significant Student t-test between the positively coded responses when compared to the neutral/negative responses (t = 1.23 [df = 22], p = 0.23). Faculty attitudes were equivalently divided between positive and the neutral/ negative attitudes.
Faculty pursuit of knowledge and topics of interest A mean score of 6.58 (SD: 1.58; range 2–8 of 0–9 possible) was found from faculty knowledge of gerontological issues. Faculty’s pursuit of gerontological knowledge mean was 3.32 (SD: 1.49; range 1–5 of 1–5 possible). The most common topics of interest in gerontology were insurance (31%), physiology of aging (31%), community resources (27%), and elder abuse (27%) (Fig. 2). In addition, 23% of the faculty listed caregiver strain, end of life issues, spirituality and specific disease conditions as areas of educational need. Faculty knowledge was significantly related to pursuit of knowledge with r = 0.54, F(1,22) = 8.85, p = 0.007.
35
Percentage of Respondants
31
Percent
31
30
27
27
25 20 15 10 5 0
Physiology of Aging
Insurance
Elder Abuse
Community Resources
Topics of Gerontology interest
Figure 2
Topics of interest for continuing gerontology knowledge.
Ensuring a knowledgeable and committed gerontological nursing workforce
51- 75%
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>76%
26- 50% <5 %
5- 25%
Figure 3 Gerontological content in master syllabi. Note. Starting at top right, first slice represents 44% of total numbers of courses surveyed, followed clockwise with 34%, 11%, 6%, and 5%.
Dissemination of gerontological information Faculty rated the majority of courses (44%) to have less than five percent of gerontological content in the master syllabi in courses they taught in the previous year. Thirty-four percent of courses were rated at having 5–25% gerontological content in their syllabi, while 11% had 25–50%, 6% had 51– 75% and 5% had 76–100% gerontological content in the master syllabi. Higher percentages of gerontological content are found in few courses as depicted in Fig. 3.
Discussion Results: attitudes toward older adults Three of the most common attributes chosen by the faculty fell into the goodness dimension of the AGED Inventory (honest, sincere, and considerate), while two items, sociable and productive fell into the positiveness dimension. Additional attributes chosen by the majority of faculty include generous and wise (goodness dimension) and involved (positiveness dimension). All these attributes have been judged to be evaluative and serve as a good report of attitudes (Knox et al., 1995). One attribute, active, was chosen by the faculty and is characterized as a vitality item. Another item, dignified, was chosen by 78.3% of the faculty and it is characterized as a maturity item. These two attributes are judged as descriptive items. They are better utilized in assessing the degree of age stereotypes (Knox et al., 1995). Overall, the faculty had moderately positive attitudes toward older adults. The attitudes expressed by this faculty group are somewhat less positive than those in the literature. MacDowell et al. (1999) reported that women and college graduates
had more positive attitudes about the elderly. Fowler (1997) found that practicing healthcare professionals (radiographers) had positive attitudes about the elderly, and transferred these attitudes to their students.
Results: knowledge The faculty in this study affirms the findings in the literature in that individuals as they grow older demonstrate more knowledge about the elderly (MacDowell et al., 1999; Sherman et al., 1996). Sherman and colleagues also found that those with graduate degrees had higher knowledge scores about older adults. Topics with which faculty are most knowledgeable include normal aging and common health problems, both of which have been previously identified (Yurchuck and Kee, 1991).
Results: faculty pursuit of knowledge This study found that those faculty who had more knowledge continued to pursue more knowledge. In a study by Ryden and Johnson (1992) faculty knowledge of gerontology was found to be highly related to their current professional growth interests. This indicates that faculty with specific knowledge pursues more information in their field. Although improvements in faculty access to gerontological continuing education have occurred, there historically have been limited programs to address faculty development in gerontology (Tyson, 1992). The continuing pursuit of knowledge in a subject is a common prerequisite to being a good teacher in higher education (Rossetti, 2002).
Results: topics of interest The highest rated topic areas were: community resources, elder abuse, insurance, and physiology of
118 aging. All of these topics relate to AACN and Hartford recommendations (2000). Gerontology topics listed as most important for professional development in the field over a decade ago were assessment, health promotion, ethics, coping with chronic disease, and pharmacology (Ryden and Johnson, 1992). This difference seen across time is likely related to the changes that have occurred in the previous decade (Lawler, 1995). Basic knowledge and skills were not topics well established in gerontological nursing a decade ago as they are now. Healthcare has moved to the community, with the emerging questions of caregiver burnout and elder abuse.
Results: percent gerontology in curriculum The majority of nursing courses examined contained less than 5% of gerontological nursing content. There is no stand-alone nursing course dealing with gerontological nursing in the curriculum. This integration of gerontology curriculum is consistent with nursing education philosophy (Rosenfeld et al., 1999). However, it has been identified that in order to meet current needs of an aging society, more gerontological nursing content is merited across countries (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004).
Implications: faculty Major trends in healthcare demand changes in program development in nursing (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004) and these changes must start with the nursing faculty (Hanson and Waters, 1992). Faculty have the obligation to prepare the next generation to be knowledgeable in gerontology, and this knowledge has been found in the literature to improve attitudes (Yurchuck and Kee, 1991), thereby providing a committed workforce as well. In order to meet the growing worldwide need, competent faculty are needed (Baumbusch and Goldenberg, 2000). This study found moderately high faculty knowledge and moderate levels of pursuit of knowledge in gerontology. Methods to address further educational opportunities for faculty in gerontology are indicated. Many nursing faculty worldwide had undertaken nursing education at a time when little focus was placed on gerontology (Joy et al., 2000). In order to meet the needs of faculty, it is impera-
D.J. Plonczynski et al. tive that the learning experience has value. Value on the learning experience may be facilitated by problem solving involvement, evidence for the need and value of this information, and exposure to positive experiences (Letvak, 2002). Students are aware that a majority of their patient caseload will include older adults. However, little information is available about students who are attracted to gerontological nursing. The insufficient number of faculty with graduate preparation and experience in gerontological nursing contribute to the lack of interest nursing students have about careers in long term care (HollingerSmith, 2003). Current registered nurses and faculty need to look to continuing education for furthering their gerontological knowledge (Denton, 1990; Milisen et al., 2004).
Implications: curriculum Refining curriculum for increasing gerontological content is seen as the most challenging component of the educational process (Yurchuck and Kee, 1991). In their comprehensive national study, Rosenfeld and colleagues (1999) investigated the prevalence of methods used to teach gerontology to nursing students. The majority of programs integrated gerontological content into the overall curriculum (63%). Hirst and Metcalf (1989) compared the advantages and disadvantages of gerontological content integration vs. segregation in nursing curriculum. They suggested that integration is easier and more efficient, but noted that both models require faculty expertise in gerontology. In the integrated model, faculty needs support regarding the appropriate type, amount and degree of emphasis on gerontology content. In the segregated model, faculty expertise is needed to teach the courses. A multidisciplinary approach to meeting the needs of older individuals has been suggested along with collaborative work with aged care settings, services and organizations (Joy et al., 2000). Researchers (Rosenfeld et al., 1999) also inquired about barriers to incorporating gerontological content in the baccalaureate curriculum. Sixty-six percent of respondents reported overloaded curriculum and over half reported a lack of qualified full-time or part-time faculty members as ‘‘somewhat’’ or ‘‘significant’’ barriers. More than 60% of these programs reported a need for assistance with faculty development and curriculum materials, such as written materials, interactive material on the Internet and computer assisted instruction, to strengthen the gerontological nursing preparation of their students.
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National and international committees have identified the growing need to prepare nursing faculty with the knowledge and expertise in gerontology to teach pre-licensure nursing students (Thornlow et al., 2006; American Association of Colleges of Nursing and The John A. Hartford Foundation Institute for Geriatric Nursing, 2000; Milisen et al., 2004). Enhancing the knowledge and skills of pre-licensure nursing students requires first, an emphasis on faculty, followed by curriculum enhancement. Experiences in nursing education suggest that assigning specific faculty to teach the same courses all the time is unrealistic because of the limited faculty resources faced by many nursing programs (Hinshaw, 2001). Changes in curriculum may sustain ongoing learning in gerontology in nursing even when faculty change.
Limitations
Implementation
Conclusion
Plans to address the educational needs of the faculty in this study are underway. Providing faculty with knowledge about gerontology is expected to lead to more positive attitudes toward older adults, as identified in the literature. Curricular changes need to be addressed in order to provide students with the information they need to become knowledgeable and committed nurses to the increasing population of older adults.
Due to the changing population demographics, there is a growing worldwide need for professional nurses who are knowledgeable and committed to working with older adults in diverse settings. The main purpose of this study was to determine the needs of faculty and the curricula at a state university nursing program in the midwestern United States. The findings supported a moderately positive attitude of the faculty toward older adults, a moderately high level of faculty gerontology knowledge, and active pursuit of knowledge for those with higher levels of knowledge in gerontology. While teaching gerontology content to nursing students throughout the curriculum, this faculty readily identified the need for more information and resources related to important health and caregiver issues for older persons.While there is an overall awareness of the policy and service concerns of older persons and their families, these faculty members see the need to further enhance knowledge to provide the most current and best practices to the nursing providers of the future. The first step in this knowledge acquisition is to address the faculty learning needs and adjust the curriculum to reflect core content. Making this step, begins the process of meeting the larger societal need for knowledgeable and committed gerontologically savvy nurses.
Future research Research is underway to assess the perceptions of the faculty in regards to how the curricula addresses the needs of the older adult as well as the facilitators and barriers to increasing geriatric content into the curriculum. These answers could assist with the development of changes in the curriculum. In addition, assessment of the knowledge and attitudes of the nursing students is planned. Replication of this research at other institutions could assist in the determination of trends in nursing education and the need for standardized curricular changes.
Theory application According to Bogdan and Bilken (1998), it is imperative to receive input from the ‘‘real world’’ or the ‘‘real participants’’ of any research study. The evaluation process was adopted to provide each faculty participant with a voice in the identification of their own gerontological attitudes, knowledge, needs, as well as curricular content.
Although similar to nursing faculty across the United States (Merriam and Caffarella, 1999), the faculty in this study was predominantly Caucasian women with limited cultural variability. In addition, the small sample size makes it difficult to generalize these data to other groups particularly when an advantage of questionnaires is that they can be administered, and have greater power, when used in large numbers. The cross-sectional design looked at the data at one point in time. Assessing the attitudes and gerontological knowledge of faculty over time would give a more reliable look at what interventions would be most beneficial in producing change.
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