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DOCUMENT RESUME
ED 376 757 HE 027 894
AUTHOR Portnoy, Frances L.; Tanner, FrederickaTITLE Preparing Nurses To Care for the Elderly: Clinical
Placements in Nursing Homes.INSTITUTION Massachusetts Univ., Boston.SPONS AGENCY Administration on Aging (DHHS), Washington, D.C.PUB DATE 88
CONTRACT 01AT0046/01NOTE 65p.; Contains filled print throughout.PUB TYPE Reports Descriptive (141) Guides Non-Classroom
Use (055)
EDRS PRICE MF01/PC03 Plus Postage.DESCRIPTORS *Clinical Experience; Clinical Teaching (Health
Professions); Cooperative Programs; CurriculumDesign; Graduate Study; Higher Education;Institutional Cooperation; *Nursing Education;*Nursing Homes; *Older Adults; Partnerships inEducation; Program Design; Student Placement;Undergraduate Study .
IDENTIFIERS University of Massachusetts Amherst; University ofMassachusetts Boston
ABSTRACTThis paper offers documents from and descriptions of
a collaborative project in clinical placements of student nurses innursing homes as part of a nursing education program. The originalproject participants were the College of Nursing at the University ofMassachusetts/Boston (UMass/Boston); the division of Nursing at theUniversity of Massachusetts/Amherst, and the Massachusetts Long TermCare Foundation, an education .and research arm of the MassachusettsFederation of Nursing Homes. Individual sections address: (1) the
need for nurses in institutions providing long term care, long termcare facility in Massachusetts, and a comparison of acute care andlong term care facilities; (2) university linkages with nursing homes(choosing a placement site, facility objectives); (3) gerontologicalnursing/long term care in the undergraduate nursing curriculum(curriculum overview of UMass/Boston College of Nursing BaccalaureateCurriculum); (4) clinical placements (placement and description oftwo projects for clinical students); (5) gerontological nursing/longterm care in the graduate nursing curriculum (curriculum overview,course outlines); (6) graduate clinical placements; (7) resolvingproblems; and (8) impacts of clinical placement on students atvarious levels and four recommended curriculum guides. (JB)
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Reproductions supplied by EDRS are the best that can be madefrom the original document.
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PREPARING NURSES TO CARE FOR THE ELDERLY:
CLINICAL PLACEMENTS IN NURSING HONES
Frances L. Portnoy, R.N., Ph.D.,College of Nursing, Universityof Massachusetts /Boston
withFredericka Tanner, M.P.H.
"This project was supported, in part, byAward #01AT0046/01, from the Administrationon Aging, Office of Human Development Services,Department of Health and Human Services,Washington, D.C. 20201. Grantees undertakingprojects under government sponsorship areencouraged to egress freely their findingsand conclusions. Points of view or opinionsdo not, therefore, necessarily representofficial Administration on Aging policy."
"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY
Frances L. Portnoy
TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)
("
U S DEPART MENT OF EDUCATION
EDUCATIONAL. RESOURCES INFORMATIONCENTER IERIC)
This document has been reproduced asrertowed tram the person Cr! Omani:dhotioriginating itMinot changes hiwe been made INmipmvereplodurtionduaWy
Points of view or opinion:. staled ur thisdocument do not nore}%.111ly representofficial OE RI position or policy
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TABLE OF CONTENTS
Introduction 1The Need for Nurses in Long Term Care 2Figure 1 3
Figure 2 4Figure 3 5
A Long Term Care Facility in Massachusetts 6
The Nursing Home: A Resource for Nursing Education 7
Comparison of Acute and Long Term Care 9
Section I University School of NursingNursing Home Linkages 10Choosing a Placement Site 10Facility Objectives for Serving as aClinical Placement Site 13
Section II Gerontological Nursing/Long Term Care inthe Undergraduate Nursing Curriculum 14Baccalaureate Curriculum 16
Section III Undergraduate Clinical Placements 24Clinical Placements forSophomore Year Students 25Consent Form for Sophomore Interview 26Introduction to Resident Interview -Strengths and Coping of NursingHome Residents 27Clinical Placements for Junior andSenior Year Students 32The Nursing Home as a Clinical Settingfor Community Mental Health Nursing 33
Objectives 33Agency roject Outline 35Exploring Local Service Agencies 37Placement Evaluation 40
TABLE OF CONTENTS (Cont.)
Section IV Gerontological/Long Term Care in (M.S.)Nursing Curriculum 41Curriculum Overview 41Courses in the Gerontological NursingConcentration 41Course Outline Theory PracticeSeminar II: Gerontological Nursing 43Course Outline - Working with Non-Professional Health Care Workers inLong Term Care 46
Section V Graduate Clinical Placements ClinicalProject: Development of a Resource Packet..48
Section VI Resolving Problems 50
Section VII Imps -4.. of Clinical Placements 52Sophomore Year Students 51Senior Year Students 53RN and Other Undergraduate Students 54Other Benefits of Participation 57Recommended Curriculum Guides 58
"This has been a good experience.At this nursing home, I havelearned that resident care andquality of life is a priority.There is a strong philosophyhere that this is the residents'home and the staff treatsresidents with affection andrespect...This experience in along term care facility it,crucial because here is themost rapidly growing part ofour population. This is maxfuture and we all need to takean interest in it."
A Senior Nursing StudentAfter a Nursing HomeClinical Placement
If
To Ellen Cole, Ph.D. and Lorenz Finison, Ph.D., Co-PrincipalInvestigators for their important contributions, withassistance from Judith Overdorf, R.N., M.P.H., and, ShulamitWurmfeld, R.N.C, M.S.N., G.N.P.:
To the staff, owners and residents of the nursing homes whocommitted time, energy and resources to developing clinicalplacements for students of nursing:
John Scott & Colonial Nursing & Rehabilitation Centers,Braintree & Weymouth, Ma.Michael Welch & Richard WelchRosemary Roberts, R.N., M.S.Carolyn Richards, R.N., M.S.
Long Term Care at Neponset, Dorchester, Ma.Peter GordonSharon Acker, R.N., B.A.Lyn Keithline, B.A.
Northhampton Nursing Home, Northhampton, Ma.Mr. & Mrs. LasheCarolyn Heider, R.N.Dolores Kestyn, R.N., M.B.A.
Dan Salmon, The Willows, Westboro, Ma.
To the nursing faculty and students dedicated to meet thechallenges of elder care:
To Ellen McBride for typing and preparation of the Grantreport:
To the Administration on Aging and its officers for theirsupport and encouragement:
Franklin P. 011ivierre, Regional Director, Region IWilliam Neth, Program Officer
C
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INTRODUCTION
The urgent need for well-prepared nurses in long-termcare facilities was the impetus for a collaborative projectin nursing education involving the College of Nursing at theUniversity of Massachusetts/Boston; the Division of Nursingat the Univez-sity.of Massachusetts/Amherst, and theMassachusetts Long Term Care Foundation. The Foundation isthe education and research arm of the MassachusettsFederation of Nursing Homes, the State's largest long termcare provider organization representing 750 nursing andrest homes. Funded under Title IV of the Older AmericansAct, as amended, the project had the following objectives:
To develop curriculum content and materials forschools of nursing that provides a positiveintroduction to long term care and prepares nursesto respond to the unique needs of older people.
To cooperate with nursing homes in providingclinical experiences for nursing students whichprepares them to care for frail elders and whichfosters interest in nursing home employment.
To disseminate materials developed by the Grant'sparticipants.
This report of Grant outcomes is designed to assistschools of nursing and nursing homes in the development ofsimilar projects.
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The Need for Nurses in Lone Term Care
Population trends indicate an increasing need for well-prepared registered nurses in long term care facilities.The fastest growing population group in the United States isthat 85 and older. By the year 2000, it is projected that5.1 million people will be 85; and, by the year 2030, 8.8million (or 33% of the over 65 population) will be 85 orolder (see Figures 1 & 2).
It is the group of elders over 85 that is most at riskfor institutionalization and requires increasing amounts offunctional assistance (see Figure 3). Twenty to twenty-fivepercent of those over 85 will be in a nursing home at sometime. The nursing home population will be frailer andsicker than in the past, discharged earlier due to costcontainment efforts, and requiring more complex care. Thereis a need for nursing staff who can meet the physical andpsychosocial needs of the nursing home resident and his/herfamily, to teach and supervise other staff, and to create anenvironment which encourages maximum function andrehabilitation, enhances the quality of life and providesfor a dignified death.
As the national nursing shortage intensifies and thepopulation 85+ continues its explosive growth, the crisis inlong term care nursing becomes more critical.Massachusetts, similar to other states, is experiencing ashortage of professional nurses.
Massachusetts ranks tenth in the nation in theproportion of elderly, with the number of individuals 85+most likely to require nursing home care expected toincrease 30% by 1995 and 80% by 2005. The State's 550nursing homes represent the second largest sector of theMassachusetts health care industry, employing 20% of allhealth care workers. Together these public, non-profit andproprietary long term care facilities are home to more than50,000 residents. With a nursing home occupancy rate of97-98%, the long term care industry is experiencing agrowing bed shortage.
The typical nursing home resident in Massachusetts isfemale, in her eighties, suffering from three or fourchronic conditions, and without immediate family. About 95%of all residents need help with the activities of dailyliving, and approximately 30% are non-ambulatory. In thenation as a whole, it is estimated that 55-80% of allnursing home residents suffer from some form of cognitiveimpairment.
2
FIGURE 1
Change in Elderly Populationfrom 1980 2000
70
60
50
40
30
20
10
065 74 75 84 85 &
over
Elder Population by Age Group19802000
Based on data from the Social Security Administration
8
3
FIGURE 2
Number of Persons 65+1900 to 2030
70
&.4 60
507:)
400
30t4
20
10
01900 1920 1940 1960 1980 2000 2010
Year of Census
NOTE: Increments in Years on Horizontal Scale are Uneven.
Based on data from U.S. Bureau of Census
2020 2030
FIGURE 3
Percent of Elder PopulationNeeding Functional Assistance
by Age: 1982
50
40
20
10
% of Elder Population
64-74 75-84 85+
Age
Pr"
Based on Data from U.J. Department of Health and Human Services
.1 I
5
HANDOUT
A LONG TERM CARE FACILITY IN MASSACHUSETTS
A long term care facility is a nursing center forpeople of all ages - with an emphasis on quality of life.It is for those who expect to recover fully as well as forthose who need indefinite long term care.
Massachusetts nursing homes are licensed by theCommonwealth and are staffed by trained professionals whoprovide the infirm elderly, the convalescent, and thechronically ill with essential health and social services.These services are provided in accordance with standardsdesigned to assure individualized quality care. Thestandards in Massachuetts are generally acknowledged to beamong the highest in the country.
LEVELS OF CARE
Long term care facilities are licensed to providedifferent levels of nursing care. Facilities may offer morethan one level of care for patients with varyingdisabilities. The levels are:
SKILLED NURSING FACILITIES (SNFS) providing skilled nursingservices on a 24-hours basis. Registered nurses, licensedpractical nurses and nurses' aides provide servicesprescribed by the patient's physician. Emphasis is onmedical and restorative nursing care along with physical,occupational and other therapies. This type of facility canparticipate in both the Medicare and Medicaid programs.
INTERMEDIATE CARE FACILITIES (ICE'S) providing regularmedical, nursing, social, and rehabilitative services inaddition to room and board for people not capable ofindependent living. This type of facility may be certifiedfor the Medicaid program.
RESIDENTIAL CARE FACILITIES providing sheltered living toindividuals capable of "functional independence". Theresidential care facility stresses the social needs of the"resident", rather than the medical needs of the "patient"as in SNF's and ICF's. Residents received dietary andhousekeeping services, medical monitoring, and social.,recreational and spiritual opportunities. These servicesrelieve the "functionally independent" person of theanxieties of old age or disability, allowing a fuller, moreproductive life.
prepared by Sharon Acker,Lyn Keithline
The Nursing Home: A Resource for Nursing Education
Nursing homes, like hospitals, are good places fornurses to learn and practice professional skills. They havebeen largely overlooked as clinical placement sites by nurseeducators, who have considered them to be outside the healthcare delivery mainstream and to offer few positive learningexperiences or nursing role models. We at the University ofMassachusetts College of Nursing have found, to thecontrary, that nursing homes make excellent placement sitesfor nursing students at all levels.
In addition to enabling students to acquire generalnursing skills, nursing home placements help interest andprepare nurses for careers working with the elderly in longterm care and other settings. Our own experience and areview of the literature point to positive clinicalexperiences in nursing homes as II= most helpful activitiesin fostering greater interest in nursing home employment andin developing the required ski/ls and attitudes ingerontological nursing.
* NursinII homes are Dlaces of major nursingresnonsibilitv. Nursing care is the primaryneed of most nursing home residents. The majoremphases in health care of this population arefunctional problems, which are in the realm ofnursing assessment and management.
7
* Nursing homes offer students an opDortu_n_ity to21av a multi-faceted nursing role. Long term carenurses can provide direct patient care, superviseand coordinate the care rendered by others, workwith residents'families, teach residents andstaff, manage personnel, work with communityagencies, initiate group activities to meetresident needs, conduct research, and evaluatequality of care.
Nursing homes provide a very challenging patientcare expexience. Far from being custodial innature, the nursing care required by residentswith multiple social, physical and psychologicalproblems is complex and rehabilitative, growingever more so as the long term cars populationbecomes older and frailer. Students confrontimportant issues of death and dying, and providecomfort for eldors and their families.
* Nursing homes offer an environment conducive tothoarmaiLitisanaiatiantsinzaAsill1 The paceof these institutions is somewhat slower than inacute care settings, the residents present a widespectrum of problems requiring nursingintervention, and the census is more stableallowing students to follow their patients forlonger periods of time.
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a
HANDOUT
COMPARISON OF ACUTE CARE AND LONG TERM CARE
ACUTE CARE HOSPITAL LONG TERM CARE FACILITY
The patient/resident is:* more dependent * more independent* in a passive role * in an active role* acutely ill or in need of * chronically ill or in needspecial services of skilled nursing care
* seen daily by a physician * seen occasionally by aphysician (usually monthly)
* admitted for days * admitted for weeks, months,years
* less concerned with social * more concerned with socialand recreational needs and recreational needs
The treatment is:* related to the reason * related to multiple
for admission (injury, problems, includingdisease, etc.) psychosocial.
* "cure oriented" * aimed at rehabilitation,restoring and maintainingwell-being
Nursing Assistants:* have responsibility for * have responsibility for morefewer patients residents
* have less freedom to help * have more freedom to helpplan patient care plan patient care
* perform many technical * perform fewer technicalskills skills
* give limited rehabilitative * perform more rehabilitativenursing care, little to do nursing care and deal morewith patient's personal life with residents' personaland psychosocial problems live and emotional problems
* usually not required * required in some states toto have training/ have special training/certification for acute certification for LTCcare hospitals facilities
* have many supporting * have few supportingpersonnel available in personnel available in thethe hospital LTC facility
or
Will, C., (1986) Being a Long Term Care Nursing Assistant.et al Brady Communications Co., Inc.; A Prentice
Hall Publishing Co., Bowie, Md. p 3, table 1-1.
c--
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SECTION I
UNIVERSITY SCHOOL OF NURSING -NURZING HOME LINKAGES
We have found that collaborating with local nursinghomes on student education brings us both closer to ourcommon goal of improving resident care. Yet, because longterm care facilities and university schools of nursing areunfamiliar partners with different missions,time, energy,and commitment are required to establish good workingrelationships, plan and implement mutually beneficialclinical experiences, and resolve problems through ongoingcommunication.
flasaatinaaalacsmantlita
Long term care "complexes", Ashmont Manor/NeponsetHall (Long Term Care at Neponset) in Dorchester,Massachusetts, and John Scott and Colonial Nursing andRehabilitation Centers in Braintree and Weymouth,Massachusetts, served as placement sites for ourundergraduate nursing students. Graduate student clinicalplacement was at the Northhampton Nursing Home inNorthhampton, Massachusetts. Additional nursing homesparticipated in the original grant planning group, welcomedstudent visits, and served on a project advisory committeealong with experts in gerontology and representatives fromnursing schools and homecare agencies.
Long Term Care at Neponset includes two separateintermediate care facilities located in close proximity.Like the majority of American nursing homes, they areprivately owned, profit-making facilities with the sameowner. Ashmont Manor has 77 beds and Neponset Hall has 98.The average resident in both homes is 85 years of age,female, and Caucasian. Ninety percent of the residents arecovered by the Medicaid program.
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1t1
John Scott and Colonial Nursing and RehabilitationCenters are two, multi-level skilled nursing andintermediate care facilities with the same privateownership. John Scott has 200 beds, while Colonial has 211.The facilites house adult day care, childcare for nursinghome employees, and an affiliated homecare agency. Theowner also operates nearby senior housing.
Northhampton Nursing Home, under private ownership, isa skilled and intermediate care facility with 164 beds; 41pediatric extended care; and, 82 for elderly.
When our plan to work with area nursing homes wasannounced in the Massachusetts Federation of Nursing HomesNewsletter, we received requests to serve as placement sitesfrom facilities throughout the state. Long Term Care atNeponset,John Scott & Colonial, and Northhampton NursingHome were selected for participation in the project at theFederation's recommendation and after site visits by facultyand meetings with facility management. Among thecharacteristics of the complexes contributing to projectSuccess were
Owner/administrators with vision who appreciatedthe need to interest and train nurses for careersin long term care, and who were willing to devotethe resources of thei facilities to a projectaimed at the long term solution of an alreadysevere labor shortage. Administrators werereceptive to innovation and eager to have theirfacilities be in the forefront of nursing homecare.
Adequate staffing and exemplary care in a home-like environment. We wanted our students to seenursing home care at its best so that they wouldlearn to "do things right" and come to appreciatethe challenge and reward of a career in long termcare. We were also concerned that nursing homeswith pressing recruitment and retention problemsmight look to the student nurses to lighten thecare burden of over-worked staff. Whilebenefiting the facilities in other ways, projectparticipation actually added to theresponsibilities of certain key staff.
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4 4
Employees qualified to serve as clinicalinstructors and project preceptors. Although ouroriginal goal had been to award facultyappointments to masters-prepared nursing homestaff willing to teach and supervise our studentsduring their clinical placements, master'sprepared nurses are a rarity in long term carefacilities. We worked out other equallysatisfactory arrangements with the homes. AtJohn Scott and Colonial, two on-site StaffDevelopment Coordinators worked closely withUniversity faculty to supervise student clinicalexperiences. They received partial salary supportfrom the University to help offset their increasedteaching responsibility. At Long Term Care atNeponset, on the other hand, the clinicalinstructor was a University faculty member who hadpreviously been a geriatric nurse practitioner atthe facility. A variety of nursing and otherstaff at the nursing homes served as preceptorsfor student projects and graduate placements, inconsultation with nursing faculty.
After selecting the placement sites and identifyingclinical instructors, University faculty and nursing homestaff worked together to develop clinical experiences thatwould benefit the residents, meet course objectives andstudent educational needs, and provide a positive learningexperience in long term care. An affiliation agreement weltsdrafted, and its salient features were shared with theentire staff of all facilities through meetings andmemoranda.
Regular meetings with the homes and ongoing dialogue,clarification, and compromise marked the 20- month grantperiod. Administrative nursing home staff, clinicalinstructors, and project preceptors attended a College ofNursing faculty meeting to describe their work, and facultyvisited the homes to observe the placement program and togive in-service training. Other long term care institutionsaround the State were kept abreast of project developmentsthrough the Massachusetts Long Term Care FoundationNewsletter.
FACILITY OBJECTIVES FOR SERVING AS A
CLINICAL PLACEMENT SITE
1. To enhance the quality of life for the resident.
2. To increase the quality of services delivered to theresidents.
3. To foster the development of positive attitudes towardsgerontological nursing.
4. To actively participate in and with the community atlarge. (Networking)
a. To increase community knowledge, enhanceunderstanding and allay misconceptions or fearsabout the "aging process".
b. To reinforce the growing concept that NursingHomes are a part of the continuum of long termcare services.
5. To solidify a relationship with the academic community.
a. To enhance the esteem of both nursing home andindividuals who choose to work within thesefacilities.
b. To narrow the gap between the System devoted tothe delivery of services to the frail elder andthe System devoted primarily to the disseminationof knowledge.
1.9Prepared by Sharon Acker,
. Lyn Keithline
SECTION II
GERONTOLOGICAL. NURSINGYLONG TERM CAREIN THE UNDERGRADUATE NURSING CURRI CULUM
Gerontological nursing does not yet receive sufficientemphasis in the nursing curriculum. Despite dramaticdemographic shifts, schools of nursing are only beginning toteach their students about normal aging and about thepathological processes common in older adults. Few nursingtextbooks address aging and long term care, and eventextbooks used in gerontological nursing courses emphasizecommunity and acute care issues of the elderly and makeinsufficient references to nursing homes.
Introducing Any new content into the very fullundergraduate nursing curriculum is difficult. Most nursingfaculty feel that there is already too much material tocover and too little time to teach.
University of Massachusetts at Boston faculty werereceptive to incorporating gercutological content and longterm cars concerns into the nursing curriculum, althoughthere were no curricular obiectives in this area in place atthe start of the grant period. The College of NursingCurriculum Committee played a key role in facilitatingdiscussion of needed curriculum modifications and indrafting the following recommendations adopted by the fullfaculty in the Spring of 1988:
20
1 I.
To thread gerontological nursing throughout theundergraduate curriculum by making modestadditions. primarily in emphasis, to existingcourse objectives at all levels. (Another optionconsidered but ultimately rejected involvedconsolidating all gerontological nursing contentinto a separate course.) The CurriculumCommittee assisted in formulating the newobjectives and is helping to implement them bydeveloping resources and appropriate teachingmaterials for faculty.
To enhance faculty interest and preparation ingerontological nursing and long term care byencouraging the teaching staff to take advantageof continuing education offerings as well asexisting expertise within the College of Nursing.
To suggest that one of the two required Growth andDevelopment courses be on aging. A requiredreference for second year students will be arecommended textbook on gerontological nursing foruse throughout their undergraduate education.
CurriculumOverview
An outline of the University of Massachusetts/BostonCollege of Nursing baccalaureate curriculum for generic andR.N. students is presented below. Courses which now placegreater emphasis on gerontological nursing and long termcare are highlighted with an asterisk. Three of thesecourses also require clinical nursing home experience asnoted. Newly adopted curricular obiectives for classroominstruction and for clinical placements follow thecurriculum outline. The nursing home placements aredescribed in detail in Section III.
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15
University of Massachusetts at BostonCollege of Nursing
Baccalaureate Curriculum Outline(RN Completion)
Course Title Credits Nursing Home Placements &
Freshman Writing:I and II
General BiologyIntroduction to
Chemistry:I and II
3/3
4/4
Other Course Additio s
Introduction toPsychology 3
Socio-CulturalStudies 3
Nutrition 3
Elective 3
Course TitleSophomore Year
Credits Nursing Home Placements &Other Course Additions
Anatomy & Physiology:I and II 4/4
Medical Microbiology 4Growth St. Development
Courses 3/3Of the two courses required,one will be on aging.Students are required to buy atextbook on gerontologicalnursing to be used throughoutthe curriculum.
Pathophysiology* 3
Elective 3
Junior YearCourse Title Credits Nursing Homo Placements &
Other Course AdditionsHealth Assessment* 4Pharmacology* 3
Electives 6
Senior YearCourse Title Credits Nursing Home Placements &
Other Course AdditionsNursing Home PlacementNursing III & IV*
(Community/Mental Health) 10/10
Professional Issues 3
Seminar In AdvancedNursing 3
Electives 6
*Courses which now place greater emphasis on gerontologicalcontent and long term care concerns.
University of Massachusetts at BostonCollege of Nursing
Baccalaureate Curriculum OutlineUndergraduate Students
Course TitleFreshman Year
Credits Nursing Home Placements &Other Course Additions
Introduction to (See RN Completion forNursing* 1 required courses)
Health Care Studies 1
SovhomoriLanarCourse Title Credits Nursing Home Placements &
Other Course AdditionsFoundations of Nursing*3 Interview resident of a
nursing home.(See RN Completion forrequired courses)
Junior YearCourse Title Credits Nursing Home Placements &
Other Course AdditionsNursing I & II* Nursing Home Placement
(Medical/Surgical- Adult/Child) 10/10
Health Assessment*Pharmacology* 3Electives 6
Senior YearCourse Title Credits Nursing Home Placements &
Other Course AdditionsNursing III & IV *. Nursing Home Placement.
(Community/Mental Health -Maternity /AdvancedMedical Surgical) 10/10
Professional Issues 3
Seminar In AdvancedNursing 3
Electives 6
*Courses which now place greater emphasis on gerontologicalcontent and long term care concerns.
0
University of Massachusetts at BostonCollege of Nursing Baccalaureate Program
Curricular Objectives in Gerontological Nursingand Long Term Care
Course : Introduction to NursingSemester : One (Freshman Year)
Objectives for Objectives forClassroom Instruction Clinical Placements
At the completion of this course, None.the student will:
1. Identify changing demographicsand growth of the elderlypopulation requiring increasingnursing care (a "challenge tonursing").
2. Identify the nursing home andother long term care settingsas part of the continuum ofhealth care services and placesof major nursing responsibility.
3. Identify ethical considerationsin the care of the elderly.
CourseSemester
PathophysiologyOne (Sophomore Year)
Objectives for Objectives forClassroom Instruction fainiciaL2laramanta.
At the completion of this course, None.the student will:
1. Identify physiological changesthat occur as a normal part ofaging and pathological processescommon among the elderly.
?
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CourseSemester
Foundations of NursingOne (Sophomore Year)
Objectives forClassroom Instruction
At the completion of this course,the student will:
1.
Obiectives foraliaicaLl/iumetnta
Discuss special considerations 1. Demonstratein interviewing and communicating begining skillswith elderly clients. interviewing and
frail elders innursing homes,focusing on theirpositive copingabilities.
2. Identify methods of assistingfrail elders with activitiesof daily living.
3.. Identify health promotion andhealth maintenance needs ofwell elderly residents in thecommunity.*
2. Demonstrateskills in assistingelders withactivities of dailyliving.*
3. Assess healthmaintenance andhealth promotionneeds of elderlyresidents in thecommunity.*
*Not at present included in this course.
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Course Health AssessmentSemester : One (Junior Year)
Objectives for Objectives forClassroom Instruction Clinical Placements
At the completion of this course, None.the student will:
1. Describe normal and pathologicalsystems changes occurring in theelderly.
2. Describe special considerationsin history taking and assessmentof the elderly. Apply knowledgeto the functional assessment ofthe elderly person.
Course PharmacologySemester One (Junior Year)
Objectives for Objectives forClassroom Instruction Clinical Placements
At the completion of this course, None.the student will:
1. Identify age changes that haveimplications for medication useby the elderly.
2. Describe the effects ofmedications upon the elderlyclient.
3. Describe special considerationsin administering medications tothe elderly.
96
CourseSemester
Medical-Surgical NursingOne (Junior Year)
Objectives fqxClassroom Instruction
At the completion of this course,the student will:
1. Describe the effects ofhospitalization andinstitutional care onthe aged.
2. Describe alterations infunction in elderly clientsrelated to, but notnecessarily limited to:nutrition; fluid andelectrolyte balance; skincare, cardiac, respiratoryrenal, neurological, andgastrointestinal problems;sensory deficits.
3. Describe the impact of loss,grief and separation upon theelderly client.
4. Describe principles ofrehabilitation and promotionof functional ability for theelderly client with multiplechronic/acute illnesses.
5. Describe nursing researchrelevant to nursing care of theelderly client.
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Objectives forClinical Placements
1. Apply thenursing process toassist elders inadjusting to thehealth caresetting, demon-strating skills indealing with theconfused or agitatedelderly client.
2. Utilize thenursing process as aframework to providecare to elderlyclients instructuredenvironments.
3. Develop nursingcare plans whichconsider the impactof loss and grief.
4. Apply principlesof functional main-tenance and restor-ation to the elderlyclient.
CourseSemester
Community and Mental Health NursingOne Semester (Senior Year) (Two SemestersR.N. Completion)
ajectives forClassroom Instruction
At the completion of this course,the student will:
1. Describe alterations incognition and psychologicalchanges found in the elderlypopulation (i.e., depression,confusion, chronic mentalillness, Alzheimer's Disease).
2. Analyze family structure andother supports available tothe elderly person in thecommunity and the institution.
3. Describe counseling andgroup leadership skillsuseful in assistingindividuals and groupsof elderly clients.
4. Analyze functionalassessment toolsappropriate for assessmentof the elderly client.
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Ob3ectives forClinical Placements
1. Apply nursingmanagement skills tothe care of a frailederly nursing homeresident withmultiple physio-logical and psycho-logical problems.
2. Observe andanalyze thestructure andprocess of theorganization orcommunity settingwhich can facilitategood quality of lifefor the elderlyperson.
3. Apply counselingand group leadershipskills,, with appro-priate supervision,to assist individ-uals and groups ofelderly residentsand families toreach their maximumfunctionalpotential.
4. Utilizefunctionalassessment tools toevaluate healthstatus of theelderly client.
CourseSemester
Community And Mental Health Nursing (Cont.)One - Two (Senior Year)
Objectives forClassroom Instruction
5. Analyze health policyregarding elder health carein the community and in thenursing home.
6. Describe discharge planningpractice.
7. Discuss nursing researchrelated to care of of theelderly in the communityand the nursing home.
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Objectives forQUI:U211.121=m 2nts.5. Observe andanalyze aspects ofthe health caredelivery systemavailable to theelderly population(a continuum ofcare).
6. Develop. discharge planswhich facilitatecare of the elderlyperson.
SECTION III
IMILERGEADLIAILSZLINICALMAGEKENTS.
Studies concerning the relationship between clinicalexperience in a nursing home and student attitudes towardsworking with the aged are inconclusive about the best typeof experience and the level of student most likely tobenefit. Some studies indicate positive outcomes whenstudents practice basic skills in the nursing homeenvironment; others conclude that placement is moreappropriate for senior students. A number of researchershave found the most favorable response to elder care whenstudents are first introduced to the normal aging processand well elders in the community.
We believe that undergraduate students at all levelscan benefit from nursing home placements and that a varietyof positive experiences are possible at each level. Withour participating long term care facilities, we developed amodel of placements for sophomore and senior students, andbegan planning clinical experiences for students at theJunior level.
Seniors, particularly the R.N. group, were targeted forthe longest and most intensive training because older, moremature nurses have been found to be the most interested inlong term care. More experienced nurses are also betterable to appreciate and respond to the complex care needs ofnursing home residents. By making a nursing home thestudents' last placement site before entering the jobmarket, we hoped to have a greater impact on their ultimatecareer choice.
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4.1011 ...
In an earlier pilot program with Ashmont Manor/NeponsetHall, the nursing home was successfully used as a site toteach beginning students basic nursing skills includinghygiene, transferring, positioning, and vital signs.Testing a different approach during the grant period, weasked sophomore students in Foundations of Nursing tointerview an elderly nursing home resident using astructured interview instrument which emphasized theresident's strengths and coping abilities. This briefexperience gave generic students just beginning theirclinical work an opportunity to develop skills ininterviewing and communicating with frail elders. It wasintended as a positive encounter with a dependent olderadult and an introduction to the world of the nursing home.
The students were given a semester to complete theinterview. We required a three-five page paper summarizinginterview findings and the students' reaction to theexperience, as well as asking for a brief oral report inclass.
The College of Nursing faculty arranged residentinterviews at a number of local nursing homes. In a letterrequesting permission for the interviews, we asked thefacilities:
1. To select residents willing and able to sharetheir experiences with a student.
2. To obtain each resident's written consent.
3. To designate a staff contact with whom individualstudents could schedule their visits.
The importance of selecting alert, well-adjusted elders forstudent interviews was emphasized.
Under consideration for the future is the use of acuteand long term care settings as sites for the acquisition ofskills in assisting elders with the activities of dailyliving.
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CONSENT FORM FOR SOPHOMORE INTERVIEW
Dear Charge Nurse:
The sophomore nursing students at the University ofMassachusetts at Boston have been asked to interview anursing home resident'as part of their learning experiencein their Foundations of Nursing Course. This assignment isdesigned to assist the student to assess the strengths ofthe elderly person, and thus will focus on those personalcharacteristics and experiences that the residents regard aspositive. Would you assist us in this process by choosing aresident for interview who will benefit from the experience.
Thank you for your help.
CONSENT.10313
has my permission to interview me(Name of Student)
at(Name of Facility)
(Resident's Signature) (Date)
(Witness's Signature) (Date)
2')
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INTRODUCTION TO RESIDENT INTERVIEW
ItrstnathacuslCsain
Long term care, viewed from a continuum, is theprovision of a broad array of services which may becommunity based, in the home, or in institutional settings.All of these settings will present a challenge to theprovision of nursing care for the at-risk population, thosewho utilize the majority of nursing and medical careresources in the country.
11 People tend to think aboutgrowing old in terms of biologicalchange, that is, in terms of physicalloss or decline. Experience, however,tells us that understanding growing oldonly in terms of the body and itsdecline is to misunderstand the heartof the aging process itself. Humanscannot be explained or understoodmerely in terms of their bodies. Considerthe example of a 97 year old woman who wasfully alert but confined (because ofbroken hips) to a wheelchair. She waspeaceful and acceptant and a delight toeveryone. When asked how she managed tosmile and stay relatively content, shereplied gently, "It's my legs that areparalyzed, not my heart.". Or considerthis conversation between two 80 year old
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5tranzthk and Coin of Nursing Home Residents
introduction (Cont.)
women who were sharing the difficultiesof being wheelchair-bound and almosttotally dependent. One woman said witha sigh, "It's a long trek", the otherwith empathy added, "and we've got to bestrong to stand it.". An observer wouldknow that she was referring to a strengthother than physical and would sense thatthese two weak, elderly people wereactually great and strong people. Theirbodies were indeed in decline, but theircourage and patience had grown and developedin spite of physical loss."
Futrell, et al. (1980) Primary HealthCare of the Older Adult. North Scituate,Ma.: Duxbury Press, p. 232.
Objective
This project is designed to assist the student inassessing the strengths of an elderly person who resides ina nursing home.
Introduction
Listening to what the residents have to say aboutthemselves and their lives in a nursing home is a crucialrequirement in providing appropriate nursing. While somenursing home residents are unable to communicate easily withvisitors duo to severe physical and psychologicaldisabilities, others are very eager to talk and to havesomeone listen to them. Their opportunities to communicateare often limited by the inexperience and shortage of staff,few or no family or friends and visitors, and the generalreluctance and lack of interest in our society in what ouroldest citizens have to say.
Strengths and Coping of Nursing Home Residents
Entering and living in a nursing home demands complexadjustments for the resident. The nursing home becomes thepersons home where all needs--physical, psychological andsocial-- are to be met. This is a lot to be demanded of aninstitution. For some residents, the move was traumatic,involving grieving for many losses; for others, it was arelief from painful and frightening situations andisolation in which they could not care for themselves. Wethink of these frail elders as needy, weak, and chronicallydisabled, but often do not recognize that they may retaintheir memories, their personalities, their intelligence, andbring strengths to bear to this new life in the long termcare institution.
These strengths can be in the physical dimension.utilizing whatever physical strengths they have andmaintaining and improving function whenever possible; in thepsychological dimension. utilizing memory and life review,maintaining a positive outlook towards life, coping withlosses, maintaining a present orientation, and seeking smallpleasures whenever possible; and, in the social dimension.developing and maintaining old and new social contacts,finding personal interests and activities, relating toothers. Often these represent very small gains oropportunities which, however, can enrich the minute, thehour and the day of the residents' present living situation.
It is important to note that much will depend on whatthe actual situation has to offer. Although the presentproject will not be an assessment of the nursing homeenvironment, the structure, staff and general environmentplay a major role in the possibilities open to the resident.
Interview Method
This interview will rely primarily on the residents ownassessment of themselves--self-reporting. Arrange with thestaff for a good time to visit and a suggestion as to whomto visit. Face the resident so she/he car see and hear youwell. Be sure she/he is comfortable.
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Strengths and Coping of Nursing Home Residents
Introduce yourself and the reason for your visit--aninterest in what the resident of a nursing home thinks abouther/himself, so that you can prepare to give good care toothers in nursing homes. Assure the residents that what theysay will be confidential and that the notes you take will beseen only by you and your instructor.
You will need to speak clearly and slowly. Deal withone thing at a time, and be patient if the resident is slowin responding or gets "off the track" (sometimes this is themost important part of the interview, so keep good notes).
Tell the resident at the outset how long you can stay.If the resident seems tired, cut the interview short, and ifpossible return at another time. If the resident wishes youto remain longer than you can, remind him/her of your timelimit. It will be helpful if you let the resident know fiveminutes before you plan to leave, so you can prepare him/herfor your leaving, and allow him/her to say whatever he/shehave on his/her mind before you leave.
Enjoy talking with these older persons. They haveexperienced a great deal of living.
jnterview
1. Observe the resident and describis the person.Age, sex, mobility, use of aids (hearing, glasses,cane, walker, etc.), skin clarity of speech.
2. Directions for the interview: Tell the residents thatyou are going to ask them some questions aboutthemselves by having them complete some sentences. Youwill make some suggestions and then ask the residentsif they can add some of their own thoughts and ideas.(If it is apparent to you that the resident cannot dosome of these things, even with help, then omit thequestion.)
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Interview of a Nursin2 Home Resident (Cont.)
Interview (Cont.)
Question 1: First we will talk about the things you areable to do (even with help): I am able to...(suggest: wash my hands and face; comb myhair; feed myself; go for a walk; exercisemy arms, my legs...). What other things areyou able to do? (Record all answers,including comments made by the resident).
Question 2: Now I will ask you about some of the thingsyou enjoy. Do you enjoy: Remembering thepast? Any special incident? Meals, orspecial clothes (which ones)? Listening tomusic? Watching TV (any special programs)?Special activities (which ones)? What elsedo you enjoy?
Question 3: Next, I will ask you something about thesocial things you do or would like to do.Visit with family or friends (who, when)?Talk with other residents (who)? Activitieswith other residents? Talk with staff (who)?Write letters (to whom)? Make telephonecalls (to whom; how often)? What otherthings do you do or would like to do withother people?
Question 4: Now that we have talked about these things, Iwould like to find out what you think are thebest things about you (urge the resident notto be shy, encourage the answer).
Question 5: Before I leave, are there any things youwould like to tell me that we didn't get achance to talk about and that would help meto understand you better? Thank theresidents for the visit and express hot.' muchyou enjoyed talking with them.
I
Clinical Placements for Junior Year Students
Nursing homes will be added to acute and chronic carehospitals as clinical placement sites for junior studentsenrolled in Medical/Surgical Nursing. These students willlearn nursing diagnosis and intervention by spending twodays a week for one semester providing total care tocarefully selected residents whose consent has beenobtained. The students will develop nursing care plans,participate in multi-disciplinary tek.7.m meetings, andcollaborate with the charge nurse and nursing assistants inthe provision of care.
Clinical Placements for Senior Year Students
During the grant period, randomly selected seniors inCommunity/Mental Health Nursing were assigned to long termcare facilites for clinical experience. Generic studentssupervised by a College of Nursing instructol, workingclosely with the nursing homes' Directors of Nursing andCommunity Relations, spent two days a week at Long Term Careat Neponset. A second group of R.N. students spent two daysa week for a total of two semesters at John Scott andColonial Nursing and Rehabilitation Centers under thesupervision of two facility Staff Development Coordinators.The latter, more in-depth placement, included opportunitiesfor experience in adult day care, homecare, and an elderlyhousing unit in addition to skilled nursing and intermediatecare facilities.
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THE NURSING HONE AS A CLINICAL SETTING FOR COMMUNITYAND MENTAL HEALTH NURSING
OBJECTIVES
Develop a one:to-one relationship with a frail elderresident of the nursing home.
a. Assess the physical and psychosocial needsof the elderly person.
b. Plan, implement and evaluate appropriatenursing interventions for this person(s).
c. Consider'the family and community, asappropriate.
d. Facilitate life review and communication ofother kinds.
* Structure the learning exnerienc_e___in the nursing hometo meet student learning needs.
a. Develop objectives based on student interests andlearning needs.
b. Utilize the diversity of resident, health, socialand phychological problems to develop knowledgeand skill (i.e., rehabilitation, post-fracture orstroke, depression, behavior problems, cognitiveimpairment, sensory and communicationdisabilities, cardiac or respiratory problems,etc.).
lamstlszagisamauidintaxactisaLskilla".a. Establish recreation and other-group activities.b. Utilize life review and reminiscence.c. Develop behavior modification skills for
appropriate clients.d. Utilize supervision to develop, analyze and
evaluate interaction skills.
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THE NURSING HONE AS A CLINICAL SETTING FOR COMMUNITYAND MENTAL HEALTH NURSING
OBJECTIVES (Cont.)
D122121212/00=11112111gi2WIlildti2IIILAILialLs.
a. Work with administrative personnel (meetings,accounting, staffing, etc.)
b. Participate in and develop educational programsfor staff.
c. Participate in overall nursing home functions andfunction as an organization.
d. Assess and evaluate nursing home functions andfunction as an organization.
e. Develop multi-disciplinary contacts (i.e.,pharmacy, dietician, social worker, chaplain,0.T., P.T.),and attend team meetings.
ikaleasthonumilazhomeaLsiaaztsiftheisisuitininnQI
a. Develop links with other agencies.b. Evaluate discharge planning and continuing care.0. Assess home and family (home visits).e. Participate in preventive health programs
(i.e., hypertensive screening).
Evaluate health 'policy issues in lona term care.
a. Describe rules and regulations (State, Federal,and local).
b. Analyze reimbursement and funding.c. Participate in legislative action.d. Analyze ethical issues in the care of the elderly.
Assess mental health
a. Observe, assess and develop interventions toassist residents with mental health problems(confusion, *depression, dementia, Alzheimer's.disease, aggression, and other behavior problems).
Components of Senior Year Clinical Placement
1. Serving as the primary nurse for a resident duringthe two days a week spent in the nursing home.The clinical instructors, in collaboration withnursing home staff selected residents expected tobenefit from student intervention while alsomeeting student learning needs in the area of careand management of mental health problems.Residents willing to participate in nursingeducation gave their written consent; eldersexpected to have difficulty with termination atthe end of the semester were excluded fromparticipation.
Students assessed the physical and mental statusof their residents; planned and evaluated nursinginterventions; supervised care provided by nursingassistants; facilitated life review and communica-tion of other kinds; and participated as fullmembers of mult-disciplinary care teams. Studentsprovided some direct physical care in order tofacilitate relationships and assess functional.abilities.
2. Conducting an agency project assigned on the basisof facility need and student interest. Projectsare in the areas of community, education, andtherapeutic intervention, all important aspects ofthe provisions of quality long term care services.
Among the projects undertaken by students andsupervised by volunteer preceptors on the nursinghome staff were the following:
Staff Development Under the supervision ofthe Director of Staff Development, studentsassisted in teaching basic nursing skills,including orientation and certificationprograms for nursing assistants. R.N.students prepared CEU programs for licensedstaff.
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Quality Assurance -_Students attended qualityassurance meetings, completed audits andpresented findings under the supervision ofthe Quality Assurance Coordinator.
Resident Education/Drug Awareness - Workingwith small groups of residents, studentsgive information regarding medication usage,drug interactions, and side effects.
Creation of a Buddy System - The Director ofRecreation and Volunteers worked withstudents to develop a resident "buddy" systemdesigned to aid new residents' adjustment tothe nursing home environment.
Socialization and Exercise - Students ledsocialization and exercise groups, includinga karate group for wheelchair-boundresidents.
Intergenerational Programs - Working with thestaff of on-site child day care programs,students developed intergenerationalactivities which brought youngsters andnursing home residents together.
Music Therapy - In collaboration with theMusic Therapist, students coordinatedresident participation in music therapygroups for the psychologically impaired.They also observed and recorded residntresponses.
Community Involvement - Under the supervisionof the Director of Community Relations,students explored opportunities for residentinvolvement in neighborhood service agencies.Higher functioning residents participated asa step towards increased independence andimproved self-esteem.
4r)
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AGENCY PROJECT OUTLINE
Project Title
Mentor/Supervisor Position:
Project Description
This project will involve:
weekly supervisionmeetingsreading or filmsprovided by facility
(check all applicable)
_work 1:1 with residents
group work with residents
independent research_____
community outreach
skill areas to be developed:
group leadership
teaching/training
interviewing
work 1:1 with staff
group work with staff
needs assessment
data collection andanalysis
therapeutic intervention
advocacy other:
Basainuonntafarsam212tisaa
Prepared by Sharon Acker,Lyn Keithline
37
3. Exploring the surrounding community and localservice agencies. Students were given theopportunity to visit other service agencies,observe and practice nursing home admission anddischarge procedures, make home visits to frailelders, and attend legislative hearings onimportant health policy issues.
Exclorinz Local Service Agencies (Examples):
Kit Clark Senior House
Kit Clark Senior House coordinatessupport services such as home care, meals andtransportation for elders living in thecommunity. The center houses an adult dayhealth program, a small Alzheimer's program,and senior drop-in center.
Dorchester House Multi-Service Center
Dorchester House provides medical,recreational and social services toDorchester residents of all ages.
River Street Detox Center
River Street Detox Center is a 20 bed,state funded program serving alcoholdependent men and women. Patients areadmitted for detoxification, the first stepin the rehabilitation process, and stay forup to five days.
N22omat...112altlxfantar
Neponset Health Center is one of_manycommunity health centers located in theBoston area. In addition to maintainingregular hours for physician visits, thehealth center provides education, referraland screening services to the NeponsetCommunity.
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Lone Island Shelter for the Homeless
The Long Island Shelter serves nearly400 homeless people of Boston and suppliesfood, clothing, shelter, and health carereferral services.
Keystone Apartments
The Keystone Apartments, located in aformer factory, is a large independent livingcomplex for senior citizens. Residents ofKeystone have their own apartment and providefor their needs independently.
The students were encouraged to structure their nursinghome experience to meet their own learning needs, takingadvantage of the many opportunities available. In additionto attending regular meetings for individual and groupsupervision, the nurses were required to maintain a dailylog of their experiences and to submit a report describingtheir agency projects. At the conclusion of the nursinghome experience, each student also completed a placementevaluation.
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PLACEMENT EVALUATION
Note: These evaluations will be kept confidential.
Name: Semester/Year
Resident Client Project
I. Please rate your experiences in each of the followingareas; and justify with a brief comment.
Placement Site: very good good fair poorComment:
Staff Interaction: very good g--1 fair poorComment:
On Site Seminars: very good good fair poorComment:
Agency visits: very good good fair poorComment:
II. Comment on your interaction with your resident client.(Include client assignment, relationship4.program andtermination issues.)
III. Discuss your agency project; include topic, amount andtype of supervision, accomplishments, and problemareas.
IV. Has this placement altered your perspective of nursinghomes?
V. Additional Comments about this placement.
Prepared by Sharon Acker,Lyn Keithline
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SECTION IV
GERONTOLOGICAL NURSING/LONG TERM CAREIN THE GRADUATE (M.S.) NURSING CURRICULUM
Curriculum Overview
The Gerontological Nursing .Concentration at theDivision of Nursing, University of Massachusetts/Amherst, isintended for the nurse who seeks advanced knowledge andclinical skills in the care of the elderly. Courses focuson the physical, psychological and sociocultural dimensionsof caring for the elderly, and the clinical experienceprovides students with the opportunity for guided practice.
COURSES IN THE GERONTOLOGICAL NURSING CONCENTRATION
Courses Required of All Students Credits
N603 Theoretical Components of Nursing Science 3
N630 Research Methodology in Nursing 3
N640 Community Health Assessment 3
N645 Health Care Systems and Nursing Practice 3
N698B Practicum (Field Experience) 6-9N699 Thesis or N697, Special Topics 3
22=itzlmiasulliurazzaranarassa'N636B Advanced Concepts in Clinical Nursing-Gerontology 3
N638 Social and Cultural Aspects of Nursing Practice 3
N648B Theory Practice - Seminar I 3
N649B Theory Practice - Seminar II 3
N662 Counseling in Nursing Practice 3
Electives
Total Credits* 48
UNIVERSITY OF MASSACHUSETTSSchool of Health Sciences
Division of Nursing
gLINIcALE NURSE SPECIALISTGERONTQLOGICAL NURSING CONCENTRATION
AMPLE PROGRAM: GERONTQLOGICAL NURSING
5emester I Credits
N603 Theoretical Components of Nursing Science 3N636B Advanced Concepts in Clinical Nursing-Gerontology 3N638 Social and Cultural Aspects of Nursing Practice 3N640 Community Health Assessment 3
Total = 12
5emester IL
N630 Research Methodology in Nursing 3N645 Health Care Systems and Nursing Practice 3N648B Theory Practice - Seminar I 3N662 Counseling in Nursing Practice 3
Total = 12
$emester III Credits
N649B Theory Practice - Seminar II 3Electives 9
Total = 12
Umester IV Credits
N698B Practicum (Field Experience)N699 Thesis or N697, Special Topics
6-93
Total = 12
- RI ftP -
UNIVERSITY OF MASSACHUSETTSSchool of Health Sciences
Division of NursingCourse Outline
- -
Rationale and Course Description
This course will be the third in a four course sequencerequired for students specializing in gerontologicalnursing. It builds on an understanding of the agingprocess and health promotion for the non-institutionalized elderly.
The course will focus on the complex problems ofchronically ill elderly clients and their families.Current issues in the provision of long term care invarious settings will provide the opportunity to testtheoretical framework being developed by the studentfor advanced practice in gerontological nursing.
Course Objectives
Students will:
1. Develp a theoretical framework for advancedpractice as a clinical specialist ingerontological nursing.
2. Demonstrate advanced practice skills ingerontological nursing which reflect ethical andprofessional standards of practice.
3. Demonstrate accountability to clients and theprofession.
4. Examine current issues in long term care includingpolicy, legislative trends and their impact on theelderly and their families.
5. Propose innovation in health care delivery for theelderly.
6. Examine models for evaluation with an emphasisupon quality assurance in long term care.
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Time Allotment
Two hour weekly seminar plus 5 1/2 hours of clinicalpractice. Some clinical conference time will be takenout of clinical time and may be combined with classtime.
Teaching Methods
Seminar presentations, clinical practicum and clinicalconferences.
Required Textbooks
Dimond, Margaret & Susan Jones (1983). Chronic IllnessAcross the Life Span. Norwalk, Ct: Appleton-Century-Crofts.
Eustis, N.,; J. Greenberg & S. Patten (1984). LongTerm Care for Older Persons: A Policy PerspectiveMonterey, Ca: Brooks/Cole.
Mil:1r, Judith Fitzgerald (1984). rasanicEithcauranialunimuDymaminapoukrimianina Philadelphia:. F. A. Davis Company.
Zazaanatedi.
Stefl, Bernita M. (1984). Handbook of GerontologicalNursing. New York: Van Nostrand Rheinhold Co.,Inc.
Simonson, William (1984). Medications and the Elderly:A Guide for Promoting Proper Use. Rockville, Md.:Aspen.
Topical Outline
1. Introduction
a. Problems and issues in care of the chronicallyill elderly (including institutionalization vs.home care).
b. Theoretical perspectives in chronic carenursing.
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2. Advanced Clinical Practice (theory, research &application of both to practice).
a. Disability.
1. Functional assessment
2. Categorization: Implications and Uses
b. Fostering Independence.
1. Rehabilitation: Concept and Resources
2. Patient Rights/Self-Determination
3. Nursing Care
c. Issues in nursing care of chronically illelders as they apply both to institutional andhome care settings.
Examples:Confusion; depression; altered mobility;altered bowel/bladder function; chronic pain;impaired social interaction. (These issueswill be selected by students. Will be examinedfrom an aggreagate as well as individualperspective and will include recent research,staff education and supervision issues, commonrelevant organizational problems, policyimplications.)
3. Current issues in long term care policy andlegislation.
4. Evaluation of long term care, quality assurance.
5. Clinical Specialist in Gerontological Nursing:
Integrating role components: teaching,consultation, advocacy, intra and interprofessionalcollaboration, leadership.
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UNIVERSITY OF MASSACHUSETTSSchool of Health Sciences
Division of NursingCourse Outline
Working with Non-orofessjanal Health CareWorkers in Long Term Care. (3 hours per week)
Rationale:
The dramatic increase in the elderly population with anaccompanying increase in the health problems associatedwith aging has increased the need for nurses and otherhealth care workers in long term care. Because of theshortage of nurses available to work in long term careand adequate economic resources to pay the, nurses mustextend their services through the use of non-professional health care workers. To maintain qualitycare, nurses must know how to train, motivate, andsupervise these workers to bring out the best of theirpotential.
SLC211MAILSztoci2tilazu.
This elective course is designed to help nurses gaincompetence in working with and supervising non-professional health care workers. It will exploreissues from the perspectives of both workers andmanagement and plan strategies that will meet theneeds of both with the ultimate goal of improvingpatient care.
Course Objectives:
1. Identify and analyze current issues in recruitmentand retention of non-professional workers.
2. Examination of the characteristics and perspectivesof workers.
3. Exploration of theories of work satisfaction andtheir application to the long term care setting.
4. Review and evaluate current legislation regulatingnon-professional workers in long term caresettings.
5. Analyze issues in collective bargaining.
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6. Analyze, in terms of applicability to the longterm care setting, the research on managementstrategies which enhance worker motivation andperformance.
Recuired Textbooks and Film:
Halbur, Bernice T. (1982) Turnover Among Nursingpersonnel in Nursing Homes. Ann Arbor: UMI ResearchPress.
Hogstel, Mildred O. (1983) Management rlf Personnel inLong Term Care.. Bowie, MD: Robert J. Lcady Co.
Film: Seven Days a Week (Terra Nova Films, Inc.)
Tooical Outline
1. Introduction and course overview. Employmentissues in long term care.
2. Opportunity: supply and demand. Recruitment andturnover.
3. Work satisfaction research. Application to longterm care.
4. Managerial climate/expertise. Research onmanagement strategies which enhance workermotivation and performance. Creative incentives.
5. The relationship between workers and clients.
6. Staff development and training: Legalrequirements; philosophy and goals; costeffectiveness.
7. Staff development and training: The adult learnerin a non-academic setting. Selection and develop-ment of materials.
8. Legal regulation of nursing homes and workers;Issues in discipline of workers.
9. Issues in collective bargaining.
10. Interpersonal relations. Race, ethnicity, andclass differences as elements of 'conflict.
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SECTION V
GRADUATE CLINICAL PLACEMENTSCliniaalkraingt
Development of a Resource Packet
UNIVERSITY OF MASSACHUSETTSSchool of Health Sciences
Division of Nursing
The rationale for this assignment is that as a clinicalresource person you will be expected to provide a variety ofup-to-date learning materials and experiences for variouslevels of nursing staff. This project will give youexperience in developing and packaging these materials intoan appropriate and useful format. The packet itself shouldbe develped at the level of a clinical specialist. Youshould select a clinical nursing problem relevant tochronic/long term care and investigate it thoroughly. Itwill facilitate your work if you select a problem that ispresent in the agency where yo are having your clinicalexperience so that you can actually implement at least partof your recommendations. Your resource paCket should bedesigned based on the orgainzation of a particular agency(but with broader applicability in mind). The following maybe used as an outline to guide in its development:
I. Condition/Nursing Diagnosis(es)
II. Description of the Condition:
Etiology, symptoms, progression, prognosis,epidemiology, social and psychological implications,medical intervention (brief), pharmacotherapeutics,other.
III. Recommended Nursing Care:
Research/clinical trials/demonstration models
Tools for dagnosis or evaluation
Unanswered research questions
Other approaches
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I. 0
IV. Administrative Considerations:
Management of groups of patients protocols
Role responsibilities: assessmentplanninginterventionevaluation
Supervisory issues:
Staff education:
V. Policy Considerations:
Institution or agencyProfessional groupsConsumer organizationsGovernment
VI. References
reportingaccountability
adminstrators/supervisorsstaff nursesaides(identify availableresources and developadditional learningexperiences as needed).
THIS PROJECT SHOULD BE TYPED ON PAPER SUITABLE FOR ATHREE-RING NOTEBOOK. COPIES WILL BE REPRODUCED AND SHAREDWITH CLASSMATES.
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SECTION VI
RESOLVING PROBLEMS
Our affiliations with the nursing homes were judgedsuccessful by students, faculty, nursing home residents andstaff, all of whom have indicated that grant activitiesshould continue and other cooperative ventures be explored.On-going communication was able to resolve problems such as:
Nursing assistants and other nursing home staffwere disappointed to find that the presence ofstudents did not ease the day-to-day burdens ofresident care. At first, some staff were alsoconcerned that "their" residents might not be caredfor properly by strangers.
Turf issues surfaced as students took on newresponsibilities and programs.
Students with advanced degrees and long nursingexperience were perceived as threatening by somenursing home staff.
11111...2=2222:27...&212
Prior to this project, The Division of Nursing at theUniversity of Massachusetts/Amherst chose not to use thenursing home for Graduate Clinical Experiences because of alack of qualified role models educated at the masters levelto serve as preceptors. This shortage is especially acutebecause this graduate program is located in the Western partof the State where there are even fewer nurses withbaccalaureate and higher degrees than in the Boston Area,and those that exist are not likely to be employed in longterm care facilities.
cn
As a result of this project, it was decided thatgraduate students do not always need a Clinical NurseSpecialist (CNS) on site in order to have a constructiveclinical experience in a nursing home setting. While theCNS hired by the grant was valuable to this project inworking out the relationships with the agency and inidentifying appropriate learning activities, she actuallydid very little one-on-one supervision of the student.Because of the close collaboration that necessarilydeveloped with staff, nursing administrators helped to fillthis role. As a result, it is felt that we can continue thenursing home assignment for graduate students after thegrant is over even though our budget will not allow us tohire additional clinical specialists.
The oreceotor role. however, is essential in bothgraduate and undergraduate education. This person may beselected from nurses in the agency, usually a nurseadministrator, who can offer them support and guidance intheir work. She would help the student to understandinternal policies and procedures and would serve as anofficial link to the medical and nursing staff.
Evaluation of student performance is carried outcollaboratively as well, with one or more persons who hasserved in the "preceptor role" being invited to complete anevaluation and attend an evaluation conference. Foracademic reasons, the faculty person must maintain finalauthority for determination of the grade, but certainlytaking strong account of the evaluation done by the agencypersonnel.
The student assigned to an agency without a mastersprepared CNS to serve as preceptor would also need to workmore closely with a faculty member who is qualified ingerontological nursing and who understands the process ofrole development. This experience would require severalon-site meetings between the faculty member and the studentand staff for the purpose of agreeing upon, implementing andevaluating the objectives of the experience. Additionaltime would have to be planned for the faculty member toreview the plans and progress of the student throughconferences and written work, although this need notnecessarily take place in the agency.
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SECTION VI
IMPACT OF CLINICAL PLACEMENTS
The period of our 22-month grant was obviously toobrief for us to assess whether our interventions had a longterm effect on student attitudes or an impact on futureemployment. However, face-to-face interviews, the logs keptby students, and questionnaires administered before andafter the nursing home placements all indicate that ourefforts were a step in the right direction. The studentsgenerally enjoyed and felt they benefitted from the nursinghome experience, and there was evidence of at least shortterm attitudinal change and perhaps career choice as well.
The responses of sophomore students, to the introductoryresident interviews were very positive:
"Mary L. is not what you'd reallycall a 'sweet old lady'...she canbe crusty, difficult, and obstinate.She always has pain, but she doesnot whine...Sha took care of herselfall her life, ran a farm mostly byherself, and much of that spiritstill remains. Speaking for myself...I am awed when I see who shereally is and what she's beenthrough."
"I was nervous about going to anursing home, as I have heard somany awful things about them...when I met Mrs. J., I saw she hadmany strengths: her charming andgentle personality, her ability toentertain herself during leisuretime, and her ability to partici-pate in decisions regarding hercare...I believe she and I weresurprised at all the things shecan do and enjoy."
At the outset, some of the senior students inCommunity/Mental Health Nursing were not sure that a nursinghome was an appropriate place to learn needed skills attheir level. A few said they would have preferred aninpatient psychiatric setting with a more clear mentalhealth focus.
After completing the nursing home placement, the samestudents responded to interview questions as follows:
"I expected to be bored anddepressed. I was interested andinvolved and very busy and farfrom depressed."
"This was my first experienceworking with the elderly outside ofan acute care setting. I have goodfeelings about the entire experienceand wouldn't have missed it."
"I wondered if I learned anything newsince I've been an R.N. for 20 years.But I liked the support and abilityto pursue ideas, the exposure tohome care, discharge planning andI think I feel more positive towardselderly patients."
"The most useful were the groups forstroke patients, in-house and out-patients. I learned, in my researchand preparation for these groups, agreat deal about stroke and itsaftermath. Although I have been anurse for 33 years, worked in acoronary unit and dealt with strokepatients over the years, this gaveme a lot of new insights."
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For both R.N.'s and other undergraduate students. theunderstanding of the elderly person and the relationshipestablished was of primary importance:
"My only exposure to nursing homeswas a brief visit to see my greataunt when I was 9...when my fatherand I walked in, I gasped at thesmell...the lighting was dim...oldpeople were everywhere, steppingout of the darkness, frightening me.Men and women slumped over inwheelchairs lining the hallwayand as I walked by, they tried totouch me. Some were yelling orcrying...to the 'nice littlegirl' to come closer. I rememberburying my face in my father's blackcoat.
My father is now 76 and when Itold him where my clinical experiencewould be, he asked me whose coat I wasgoing to hide in now. What can Iaccomplish here?...These people havenothing to look forward to...No oneloves them or cares about them...
They are dumped here until theydie. I vowed I would never put himin a place like this. Then...somethingI did not expect happened...I wasintroduced to my patient."
"Bill reminds me of one of my sons,in that he wants my undividedattention all of the time. He tellsme he misses me when Igo for coffee.I'm really becoming attached to him...I even kissed him goodbye (meeting)."
"I love to see M.'s face when hespots me in the hallway...he justbeams. For that, he always getsa hug...Today M. was covered withfeces--even the blanket. One lookat him and my response was 'don'tmove'--his response was to breakinto gales of laughter. I told himjust one more day--he began to cryagain and said, 'I'm voing to missyou'. I told M. I would come andvisit him over the summer... M.fulfilled each of the goals andmore...Maybe all he needed was tohave someone's undivided attention.The staff...has become more patientwith him since they learned he iscapable of doing things for himself.
"It bothered me...to see these elderlythat are disoriented, some yell, otherssit in silence...like a blank slate withnothing inside. Yet, when you talk abouttheir past...you find rich, productive,hard lives...It is rare in the hospitalthat I ever have the time to lit with aclient and actually listen."
Students in all groups were impressed at the range ofactivities possible in a nursing home setting:
"It is difficult to develop a toolfor data collection in qualityassurance. Developing somethingwhich looks as simple as arestorative feeding plan tool forassessment is very complex...It'sall so new and abstract, like acomputer program, small baby stepsfor the accomplishment of some taskin a specified logical sequence...I've never learned to do thisanywhere."
"I was very apprehensive, havingnever worked in a nursing home. Itis so different. The day with thenurse practitioner at the facilityopened my eyes. She has enormousresponsibility and performs a vitalfunction. She is a strong linkbetween staff, residents and physcian.Now I am interested in becoming ageriatric nurse clinician."
"Visiting home care was impressive.There is so much teaching andreinforcement...NOT hit and run- -People in their 90's in their ownhomes, talking about their families.The care is complex and can includehyperalimentation and dialysis. Infive of the six, we visited thefamily, not just the patient. I canunderstand the importance of startingthe discharge plans for each patient,the day they come 12 the hospital.The nurses are sharp, knowledgeable.The interdisciplinary meeting issuper, exchanging and expressingideas. I think I can take somethingfrom this setting to my work inacute care."
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Other Benefits of Particivation
Student involvement enabled the nursing homes toenhance existing resident programs and to developnew ones. Residents received extra time andattention from the students and were generallypleased and proud to assist in educating nursesfor the future. The nursing students also broughtmore of the outside world into the nursing home,making it a more open, less isolated community inwhich to live.
College of Nursing faculty and students becameacquainted with the varied and challenging aspectsof the nursing role in long term care. Theydeveloped an appreciation of the complexity ofresident needs and of the key position held bynursing within long term care institutions. Thestudents also acquired knowledge and skills in thecare of frail elders.
Nursing home staff morale was increased by thevisibility, recognition, and sense of being in thehealth care delivery mainstream that came withprojeCt participation. Nursing assistants andother staff learned from observing studentteaching and came to enjoy sharing their knowledgeof the residents with the newcomers.
The clinical resource packet prepared by thegerontological nursing graduate studentdemonstrated a program of skin care thatImproved resident well-being, and enhancedthe status of nursing at the long term carefacility.
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Burnside, I.
Shine, M. S.;Kopec, C. A.
(1984) Working With The Elderly: Groupprocess and Techniaues. Monterey, Ca.,Wadsworth Health Sciences Divsion, 2ndEd.
An excellent clinical guide forleaders of groups for the elderly. Itincludes an overview of types of groups,a theoretical framework of group work,and suggestions for working with elderlypersons who are cognitively impaired.The guide describes "how to" run a groupusing innovative approaches.
( 1982 ) SarantsalagicaltharAinsuafazzAntSluislciar21glatLong Term Care Facilities
American Health Care Association1200 15th St. NWWashington, D.C. 20005202-833-2050
A clearly written comprehensivemanual which addresses psychosocial andphysiological dimensions of elder care.The units include basic information onnormal aging and an overview of agingissues, pyschosocial concerns, nursingcare of problems in mobility,respiration, cardiac function,elimination,. nervous and endocrineproblems. Nutrition, fluid andelectrolyte balance, hygine, sensorydeficits, sexuality, medication anddrug administration are also covered.There is an overview of basic nursingprocedures. The bibliography at theend of each unit includes suggestionsfor audiovisual materials.
en
(1988) NANNZI Nursing Assesment andManagement of the Frail Elder
Division of Continuing EducationUniversity of KansasSchool of NursingStation 639th & Rainbow Blvd.Kansas City, Kansas 66103
Eight learning modules focus onfunctional assessment and caremanagement of the frail elderly. Thereis a clinical component as well as acurriculum content written in an outlineform.
(1983) Geriatric Educational Programfor Nurses.
National Technical Information ServidesDepartment of Commerce5285 Port Royal RoadSpringfield, Va. 22161
A comprehensive geriatriccurriculum. A 113 hour program toprepare professional nurses to: a.provide care b. educate staff c.administer and manage health care foraged population. Six volumes areparticipant manuals; two are facilitatormanuals.