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Nursing students’ knowledge and beliefs about care of older adults in a shifting context of nursing education

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Nursing students’ knowledge and beliefs about care of older adults in a shifting context of nursing education
  ORIGINAL RESEARCH Nursing students’ knowledge and beliefs about care of older adultsin a shifting context of nursing education  Jennifer Baumbusch, Sherry Dahlke & Alison Phinney Accepted for publication 21 January 2012 Correspondence to J. Baumbusch:e-mail: jennifer.baumbusch@nursing.ubc.ca Jennifer Baumbusch PhD RNAssistant ProfessorMichael Smith Foundation for HealthResearch Scholar, School of Nursing,University of British Columbia, Vancouver,British Columbia, CanadaSherry Dahlke MSN RNDoctoral CandidateSchool of Nursing, University of British,Vancouver, British Columbia, CanadaAlison Phinney PhD RNAssociate ProfessorSchool of Nursing, University of British,Vancouver, British Columbia, Canada BAUMBUSCH J., DAHLKE S. & PHINNEY A. (2012)BAUMBUSCH J., DAHLKE S. & PHINNEY A. (2012)  Nursing students’ knowl-edge and beliefs about care of older adults in a shifting context of nursing education.  Journal of Advanced Nursing   00 (0), 000–000.  doi: 10.1111/j.1365-2648.2012.05958.x Abstract Aim.  To a report a study of improvements in students’ knowledge and beliefs aboutnursing care of older adults following completion of an introductory course withintegrated adult/older adult content. Background.  Nursing schools are under pressure to provide accelerated pro-grammes to meet growing workforce demands and provide students with theknowledge they require to care for an ageing population. Thus, stand-alone coursesin gerontological nursing are being eliminated and integrated with general adultcontent. The effect of this approach remains poorly understood. Design.  A one-group pretest-post-test design was used. Methods.  Data were collected between September–December 2010. Studentscompleted the Palmore Facts on Aging Quiz, the Perceptions of Caring for OlderPeople Scale, and open-ended questions about their experiences before and aftercompleting a course with integrated adult/older content. Results.  Students’ knowledge and beliefs about nursing care of older adultsdemonstrated an important improvement following completion of the course.Qualitative findings reflected three themes: relating to older people; neglect by thesystem; having time to learn. Conclusions.  Findings from this study suggest that even when integrated withgeneral adult content, students’ knowledge and beliefs about older adult care can bepositively influenced. Furthermore research is needed to examine long-term inte-gration of students’ learning about older adult care. Nursing faculty with expertisein nursing care of older adults must develop resources and supports for theircolleagues to build capacity among nurse educators and integrate older adult con-tent throughout nursing programmes to enhance nursing practice with an ageingpopulation. Keywords:  beliefs about older adults, gerontological knowledge, nursing education,nursing students   2012 Blackwell Publishing Ltd  1  JAN  JOURNAL OF ADVANCED NURSING  Introduction Older adults are the fastest growing demographic world-wide[World Health Organization (WHO) 2007] and it is wellunderstood that with increased age there is increasedincidence of health challenges (Hickman  et al.  2007, Barakzai& Fraser 2008). Thus, it is not surprising that nurses arecaring for older adults in most healthcare settings (Kennedy-Malone  et al.  2006, Denton & Spencer 2010, CanadianInstitute of Health Information 2011), and educators areexamining curricula to determine if there is adequate theo-retical and clinical content to prepare nursing students forpractice. Scholars around the world have identified thatnursing education does not include the necessary contentabout older adult care (King 2004, Gilje  et al.  2007, Xiao et al.  2008, Deschodt  et al.  2010). Furthermore, nursingstudents are often exposed to clinical environments wherenegative beliefs and practices towards older adults areprevalent (Aud  et al.  2006, Brown  et al.  2008b, Ironside et al.  2010); these negative experiences further shape thebeliefs of the students, which in turn influence their behaviourand acquisition of gerontological knowledge (Wesley 2005).Thus, while demand for nurses with expertise in older adultcare is increasing, nursing programmes are not necessarilygraduating students who are interested in working with thispopulation.At the same time that the healthcare context is demandingnurses with expertise in care of older adults, the context of nursing education makes it challenging to ensure adequateinclusion of this area. Current recommendations state thatnursing curricula should contain both a required gerontolog-ical course with theoretical (also referred to as lecturecontent) and clinical practice components, and gerontologicalcontent threaded throughout the curriculum (AmericanAssociation of Colleges of Nursing 2000). This proveschallenging, however, for a variety of reasons, including thegrowing popularity of accelerated programmes and thecommon perception that curricula are already overflowing,creating the argument that there is simply no time for moregerontological nursing content (Barba & Gendler 2006,Deschodt  et al.  2010). It has also been observed that there areinsufficient numbers of nursing faculty with the necessaryexpertise to support gerontological teaching (Maas  et al. 2010), and there tends to be little pressure from students toprovide learning opportunities in this area of practice thatthey perceive as undesirable (Happell & Brooker 2001).These factors contribute to nursing programmes shiftingaway from stand-alone courses in gerontological nursing andintegrating this content with general adult content. Thisarticle reports on a study in which students’ acquisition of knowledge and beliefs about care of older adults wereexamined in the context of an introductory, integrated adult/ older adult course in an accelerated nursing programme. Background Theoretical framework The theoretical framework of critical realism guided thisinquiry. Critical realism holds that there is a reality that existsand it can be apprehended through a critical lens (Maxwell2008). Critical realism reflects our belief that an integratedadult/older adult course has the potential not only toinfluence knowledge acquisition and beliefs about older adultcare, but it also recognizes knowledge as a human productcomplete with social and historical contexts (Scott 2005,Lipscomb 2008). By using a critical realist theoreticalframework, this study takes the perspective that nursingstudents interpret social views of ageing when engaging intheory and clinical experiences during their educationalprocess. Thus, analysis of nursing students’ knowledge andbeliefs about older adult care requires consideration of thecontexts, both health care and nursing education, and howthey influence students’ experiences. Review of relevant literature A literature search for research published in English between2000–2010 revealed that most of the research focusing ongerontological education have been American studies detail-ing the successes and challenges of incorporating geronto-logical content into curricula (Aud  et al.  2006, Barba &Gendler 2006, Blais  et al.  2006, Burbank  et al.  2006,Latmimer & Thornlow, 2006, Plowfield  et al.  2006). Over-all, these studies share a common theme about the impor-tance of educating faculty about older adult care, wherevarious challenges have been identified, including: negativeimages of gerontological nursing amongst nursing faculty(Flood  et al. , 2009, Brown  et al.  2008a, 2008b, Xiao  et al. 2008, Deschodt  et al.  2010, Ironside  et al.  2010); perceptionsthat curricula are already overloaded (Barba & Gendler2006, Deschodt  et al.  2010); and the persistent belief thatolder adult care is simple (Brown  et al.  2008a, 2008b, Xiao et al.  2008). Issues with faculty and curriculum developmentare compounded by the negative perceptions about olderadult care among students and practicing nurses, creatingfurther barriers to inclusion and implementation of geronto-logical content (Happell 2002, Higgins  et al.  2007, Berntsen& Bjork 2010, Marshall 2010). Thus, while the healthcaresystem has high demand for nurses with expertise in care of   J. Baumbusch  et al. 2    2012 Blackwell Publishing Ltd  older adults, the context for actually incorporating geronto-logical content, that is, nursing programmes, is one thatcontinues to situate this body of knowledge as a low priority.There is also a small body of research exploring theimportant role that clinical experience plays in shapingstudents’ beliefs about older adults. Research has revealed arange of complex issues related to clinical settings (Flood et al. , 2009; Brown  et al.  2008a, Xiao  et al.  2008, Ironside et al.  2010), the knowledge and skill level of the student(Aud  et al.  2006, Ironside  et al.  2010), and the nature of faculty involvement (McLafferty 2005, Burbank  et al.  2006,Plowfield  et al.  2006).A key point of contention in the literature is the type of clinical setting for students to learn about older adult care.Although some have argued that the frequent practice of assigning students to LTRC settings for their first clinicalexperiences can give the impression that older adult care issimple, and that these clinical experiences have the potentialto leave nursing students with negative impressions of olderadult care (Aud  et al.  2006, Holroyd  et al.  2009, Ironside et al.  2010), others have suggested that these environmentscan be a positive place for senior level students to learn aboutthe complexity of older adult care, offering opportunities tointegrate theory and clinical learning through focusedassessments and interactions with interdisciplinary teams(Williams  et al.  2007). Most students learn about older adultcare in acute hospital environments. Unfortunately, thesesettings have been characterized by poor standards of care forolder people. For example, in a longitudinal study of 700student nurses, Brown  et al.  (2008a) found that many of thenegative experiences reported by students occurred on unitswith impoverished physical environments, poor staffinglevels, lack of suitable equipment and insufficient geronto-logical education for unit staff. It has been suggested thatthese kinds of clinical environments could be perpetuatingnegative beliefs about older adults among nursing students.McLafferty and Morrison (2004) for example showed thatstudents were learning about nursing practice with olderadults in clinical settings where some nurses and facultymembers treated older adults as children and where the olderadults were ‘patronized and infantilized’ (p. 451).Despite clinical settings that perpetuate negative beliefs andpractices around older adult care, it has been shownrepeatedly that nursing students’ attitudes towards olderadults can be positively influenced by faculty. It seems clearthat there is a strong relationship between faculty’s positiveattitudes towards older adults and students’ improved atti-tudes (McLafferty 2005, Burbank  et al.  2006, Plowfield  et al. 2006, Cozort 2008, McLafferty  et al.  2010). Furthermore,there is evidence to suggest that learning experiences thatcombine gerontological content with relevant practice expe-riences have a positive influence on students’ perceptionstowards older adults (Lange  et al.  2006, Williams  et al. 2007).Therefore, previous research suggests that positive beliefsabout older adults and their care can be promoted througheducation about older adult care in the classroom combinedwith learning opportunities in the practice setting withfaculty who hold positive views towards this population.Thus, examining knowledge acquisition about older adultcare alone would give an insufficient picture of the effective-ness of teaching nursing students about older adult care.Much of the research to date has been conducted in stand-alone gerontological nursing courses, yet the trend in accel-erated nursing programmes is moving towards a moreintegrated approach with adult/older adult care courses. The study Aim Nursing faculty at a large Canadian university developed anew introductory nursing course with integrated gerontolog-ical theory and clinical practice. The aim of this study was todetermine the effectiveness of the course in influencingnursing students’ knowledge and beliefs about older adultsand their care.The following hypotheses were tested: •  Nursing students’ knowledge about older adult care wouldimprove by the end of the course; •  Nursing students’ beliefs about older adult care wouldimprove by the end of the course. Design A quasi-experimental, one-group (pretest–post-test) designwas used, along with a small qualitative component (an open-ended question at the end of the study questionnaire) toprovide further context for interpreting the results. Setting An accelerated pre-licensure undergraduate nursing pro-gramme at a large Canadian university was the setting forthis study. A cohort of 120 students is accepted each year intoan 18-month programme that comprises the last five trimes-ters of a 4-year undergraduate degree. Until the 2009–2010academic year, gerontological nursing was a stand-alonecourse offered in the middle of the programme. As part of anoverall curricular revision, this course was retired, and  JAN: ORIGINAL RESEARCH  Nursing students’ knowledge and beliefs about care of older adults   2012 Blackwell Publishing Ltd  3  gerontological content was integrated with existing adultcontent throughout the curriculum. Students take what isreferred to as an ‘adult/older adult’ course in the first term of the programme, and then a second adult/older adult courseduring either their second, third, or fourth term beforechoosing a clinical specialty for their final clinical course.This study was conducted with students in their first termin the introductory adult/older adult course. Prior to begin-ning the course, the students completed a 4-week, intensivecourse in professional issues in nursing, which also includedcontent about the nursing process, documentation andphysical assessment. The adult/older adult course is the firstcourse with a clinical component. This course entails42 hours of in-class theory, 14 hours of lab practice, and144 hours of clinical instruction in an adult/older adultsetting. The in-class sessions focussed on common conditionsin major systems of the body. For example, in the cardiacsession, the focus was on hypertension and heart failure.Because most of the conditions mainly affect older adults, thiscontent was integrated throughout the course rather thanhaving stand-alone lectures about this population. Thelaboratories introduced basic clinical skills, such as medica-tion administration and oxygen therapy. The clinical com-ponent entailed a 6-week rotation of three 8-hour shifts perweek. Because of the high demand for clinical placementsfrom other Registered Nurse programmes, and also fromLicensed Practical Nurse and care aide programmes, thestudents were placed in a range of settings from long-termcare facilities to acute medicine to short-stay surgery.Importantly, all the students would have worked extensivelywith older adult patients regardless of setting. Followingcompletion of this course, all students are required to take asecond level adult/older adult course that continues to buildon the knowledge and practice experience gained in theintroductory course and many of the students will take athird adult/older adult course as their clinical focus prior tocompleting the programme. Procedure Nursing students were invited to complete the study question-naireduringtheirfirstclass(Time1)and8 weekslaterintheirfinal class (Time 2), after completing all the required theory,lab, and clinical experiences for the course. The research wasconducted between September and December 2010. Sample Forty-three of the 119 students enrolled in the course(response rate: 36%) included matching unique identifierswhen they completed the questionnaire at Time 1 and Time2. Power analysis determined that with this sample size and apower of 0 Æ 80, alpha of 0 Æ 05, the effect size was 0 Æ 30 for atwo-tailed paired  t  -test. Data collection Data were collected via questionnaire. There were a total of 45 structured questions on the survey, six demographicquestions and an open-ended question. The questionnairetook approximately 15–20 minutes to complete. Knowledge about older adult care  was measured usingPalmore’s (1980) Facts on Aging Quiz. This is a list of 25 trueand false statements to identify knowledge about older adultsas a group. Palmore’s Facts on Aging Quiz has been usedextensively and has been found to be reliable and valid innumerous studies of student learning in nursing and otherhealth disciplines (Edwards  et al.  1992, Palmore 2001,Fabiano  et al.  2005). Beliefs about older adult care  were measured using thePerceptions of Caring for Older People Scale (Burbank  et al. 2002). The instrument has 20 items expressing positive (tenitems) and negative (ten items) perceptions towards caring forolder adults. Items are rated by participants using a 5-pointLikert scale with response categories ranging from stronglyagree to strongly disagree. In this study, Cronbach’s alphawas 0 Æ 8. Demographic information  was collected using six ques-tions about gender and age, educational background andprevious experiences with older adults. Qualitative data  were collected using an open-endedquestion that invited students to comment on their experi-ences in relation to older adults in the context of the course. Ethical considerations Ethical approval was obtained from the university ethicscommittee prior to commencing this study. A week prior tothe first class, students were sent an information emailexplaining the study, with assurance that participation wasvoluntary and would not influence their progress in thenursing programme. They were invited to give their ownmatching unique identifiers at Time 1 and Time 2 to ensureanonymity. Data analysis Quantitative data were analysed using  SPSSSPSS  version 18.0software (SPSS, Chicago, IL, USA). Descriptive statisticsappropriate to the level of measurement were generated for  J. Baumbusch  et al. 4    2012 Blackwell Publishing Ltd  all study variables. Paired  t  -test analysis was used to test thestudy hypotheses. Qualitative data were hand-coded andanalysed using thematic analysis. Comments were initiallycoded and then categorized into themes. Results Sample characteristics Forty-three students provided a unique identifier to matchtheir data before and after the course. The average age was26 years (range: 20–39). Thirty-eight of the students werefemale students, and five were male students. Seventeen of the students already held an undergraduate degree and 11had a previous degree in the health sciences. Two of thestudents had a Masters’ degree. Five of the students identifiedprevious healthcare experience, which included being aregistered dietician, a health fitness consultant, or a para-medic. Main study variables The mean score for knowledge about older adult care at Time1 was 13 Æ 4 ( SDSD  2 Æ 15) and at Time 2 was 16 Æ 83 ( SDSD  2 Æ 28). Themean score for beliefs about older adult care at Time 1 was69 Æ 07 ( SDSD  12 Æ 53) and at Time 2 was 76 Æ 78 ( SDSD  7 Æ 19). Study hypotheses Hypothesis 1: Knowledge of older adult care showed animportant improvement [ t   (43)  =  7 Æ 2,  P < 0 Æ 001] betweenTime 1 and Time 2.Hypothesis 2: Beliefs about older adult care showed animportant improvement [ t   (43) = 3 Æ 4,  P  = 0 Æ 001] betweenTime 1 and Time 2. Qualitative findings A small number of students responded to the open-endedquestion. The comments illustrated three key themes: relatingto older adults; neglect by the system; having time to learn.The first theme reflects students’ beliefs about older adultcare; the other two themes reflect how students integratedtheir new knowledge and beliefs in the current healthcarecontext. Relating to older adults Many students entered the programme with previous workexperience, and some already had experience working witholder adults. At the outset of the course, a student wrote: As a personal trainer, I have trained many older adults who are inrelatively good form. I am intrigued to work with them in a hospitalsetting; it will clearly be a very different experience though rewardingall the same I hope. Others wrote about their expectations of learning to care forolder adults. A student wrote: ‘I enjoy spending time witholder adults and listening to their life experiences all the whilelearning about and gaining insight on life’. This quote alsoillustrates how students draw upon their previous conceptu-alizations and experiences with older adults in anticipatingthis aspect of their nursing education. Another studentreflected upon his/her reaction to learning about being in aclinical placement in an older-adult focused setting: I am trying to keep an open mind in regards to caring for older adultsin a nursing role. My practicum is in gerontology and initially I wasdisappointed because I wanted experience in a faster-paced environ-ment. However, my feelings on this have changed over the last fewweeks. And I think there will be a great opportunity to really connectwith and actually make a difference for older individuals in myclinical practice. This quote reflects perceptions about older adult care asslower paced than hospital care with younger people. Thecourse was set-up so that students initially had 2 weeks of in-class theory before entering the clinical areas, thus thestudents had already been exposed to some content and werestarting to develop their knowledge base about older adultcare. By providing theory about the complexity of this area,faculty were able to capture students’ interest and begin toshift their preconceptions before beginning their clinicallearning experiences.By the conclusion of the course, students wrote about howtheir beliefs about older adult care had changed: Really enjoyed caring for older adults on the medical floor. Met sometruly lovely people and families. It was easy to relate to them oftenbecause they were so comfortable with who they were (due to lifestage?). Another student acknowledged a feeling of competence bythe conclusion of the course, despite their intention to workin another area of nursing: From clinical, I was happy to learn that I am comfortable andcompetent in caring for older adults including personal care.However, I know it is not where my interests are. Neglect by the system Students clearly identified challenges within the healthcaresystem that affect nursing care of older adults. Importantly,several wrote thoughtfully about the challenges of providing  JAN: ORIGINAL RESEARCH  Nursing students’ knowledge and beliefs about care of older adults   2012 Blackwell Publishing Ltd  5
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