Submitted by by Kristen Morris, SN; Carol Eliadi, APRN, EdD, JD
The researcher, a baccalaureate nursing student, was interested to know why, with the rapidly growing population of older Americans, there was not a stand alone course related to the care of the geriatric patient offered within her SON curriculum. What were the barriers that failed to allow a stand-alone course for geriatrics? Stand-alone courses are offered for pediatrics and psychiatric care, but not for the care of the geriatric patient. The researcher wanted to know if this situation was consistent with other baccalaureate nursing programs within Massachusetts and with baccalaureate nursing programs nationally. The researcher believed that nurses must be adequately prepared to care for the rapidly growing shifting demographics related to the older population and was interested to see how Massachusetts’ baccalaureate nursing programs compared to the other baccalaureate nursing programs nationally in offering geriatric content and why discreet geriatric courses may not be offered.
The population of older Americans ≥65) is increasing dramatically and is estimated to grow by 75% from 2010 to 2030. This would be an increase of 39.4 million Americans in 2010 to 69 million Americans in 2030. To understand how rapidly the older American population is expected to grow, the future estimated growth should be compared to the current growth of the older American population. Currently, the growth of the older American population is estimated to increase from 33.5 million in 1995 to 39.4 million in 2010, a growth of 17%. This current growth is only 5.9 million Americans in 15 years compared to the future growth of 29.6 million Americans in 20 years. (Administration on Aging, 2004)
The rapidly increasing older American population indicates that nurses will have to care for older Americans on a more frequent basis and will have to be adequately prepared to care for this growing population. The need for a nurse workforce prepared to care for a growing proportion of older, potentially sicker patients poses enormous challenge to nursing education. Nurses will need enhanced skills to meet the growing healthcare demands of older patients (Rosenfeld et al., 2005). The purpose of this descriptive, quantitative study was to identify the gerontological curricula content within Massachusetts baccalaureate nursing programs, describe how curricula trends in Massachusetts vary in relation to the national curricula trends identified by Gilje, Lacey and Moore (2007) and identify the barriers, if any, to reaching the standards set by the American Association of Colleges of Nursing (AACN) in Older Adults: Recommended Baccalaureate competencies and Curricular Guidelines for Geriatric Nursing Care.
REVIEW OF THE LITERATURE
The computerized databases used to locate relevant literature were the Cumulative Index of Nursing and Allied Health Literature, CINAHL, and PUBMED after the year 2002 with search restrictions of full text and English. The keywords used were nursing, geriatrics, gerontology, education, studies and curriculum used in a variety of combinations. There was a vast amount of information discussing the importance of gerontology within a curriculum, but limited studies have been conducted to determine the specific gerontology content of baccalaureate nursing school curriculum. After reviewing the literature, the researcher determined that there have been four major studies conducted to identify curriculum trends within baccalaureate nursing programs. One study, conducted in 1997, was used as a baseline study for studies conducted thereafter and was included in the following literature review.
Rosenfeld, Bottrell, Fulmer and Mezey (1999), conducted a national survey reporting the baseline gerontological content within baccalaureate nursing programs. This study was conducted due to the limited baseline data defining the gerontological content and faculty preparation within baccalaureate nursing programs and provides the necessary data for future studies to have a comparative basis (Rosenfeld et al., 1999). As a follow up to this national survey a similar study was conducted by Rosenfeld et al. (2005) to determine if additional resources and new initiatives had been effective in influencing the gerontological curriculum with baccalaureate nursing programs. Substantial foundational resources were created to strengthen gerontological nursing knowledge in baccalaureate nursing programs after the baseline study done by Rosenfeld et al. (1999). In 2000, the AACN, in collaboration with the Hartford Institute, published Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Gerontological Nursing Care. This document promotes the incorporation of specific gerontological nursing content/objectives into baccalaureate nursing curriculum (Rosenfeld et al., 2005).
Grocki and Fox (2004) conducted a regional study to discover the specific content that was being included in four year undergraduate nursing programs within the United States and how this data compared to the nation’s demographics. The most recent study by Gilje, Lacey and Moore (2007) was also conducted to determine if geriatric and gerontology issues in United States baccalaureate schools of nursing had been influenced since the publication of the AACN’s Older Adults: Recommended Baccalaureate competencies and Curricular Guidelines for Geriatric Nursing Care.
Similar themes are addressed in each of the four previously mentioned studies. The first is the importance of offering a stand-alone course for gerontology versus integrating the gerontological material into courses already being offered. According to the demographic trends, the probability that a registered nurse will be delivering care to an older American is much greater than the probability the nurse will be delivering care to a child or a patient with a psychiatric-mental health diagnosis, but a majority of nursing programs do not offer stand-alone courses in geriatrics, but offer stand-alone courses in pediatrics and psychology (Rosenfeld et al., 1999). The results of Rosenfeld et al.’s (1999) study revealed that 23% of baccalaureate nursing programs require a stand-alone course and the results of Grocki and Fox’s (2004) study revealed 25% of programs require a course in gerontology which suggests a majority of nursing students are graduating without a focused concentration in care of the elderly. The programs that claim to integrate gerontology into the curriculum actually cover “very little gerontological content” (Rosenfeld et al., 1999, p. 91). Gilje, Lacey and Moore (2007) identify that “the issue of integrating geriatric content into curricula or offering a stand-alone course in geriatrics is a subject of continuing debate” (p. 22), but along with the other studies recognize the importance of offering a stand-alone course.
The consensus amongst the studies suggests that the lack of a required stand-alone course conveys messages to society. “When nursing does not address the geriatric population to the same extent as the pediatric population, for example, a message is sent that this population is of lesser importance” (Grocki & Fox, 2004, p. 50). This message can also affect the attitudes of nursing students toward the older American population. “Courses in gerontology may develop or increase students’ interest in the older population” (Grocki & Fox, 2004, p. 50). Gilje, Lacey and Moore (2007) also suggest that a stand-alone course is important for students to value the care of older people. The authors believe that a stand-alone course is needed, similar to that of other specialty areas, to adequately prepare students to care for this population (Gilje, Lacey & Moore, 2007). Gilje, Lacey and Moore (2007) and Rosenfeld et al. (2005) both compare their current surveys with the study conducted by Rosenfeld et al. (1999). Gilje, Lacey and Moore found that in 2007, 76% of baccalaureate programs required a stand-alone course compared to only 62% in 1997. Rosenfeld et al. (2005) determined that there was no increase in programs offering stand-alone courses from 1997 to 2003, the programs that did offer stand-alone courses were now requiring these courses rather than offering the course as an elective. The results of these studies suggest a trend toward requiring a stand-alone course.
Another common theme addressed is the barriers to offering a stand-alone course in gerontology. The two primary barriers identified were curriculum overload and faculty preparation. Curriculum overload is when “content is constantly added to curricula to reflect advances in biomedical and nursing knowledge and important trends in the health care system in general and the discipline of nursing in particular, while little, if any, content is taken out” (Ironside, 2004, p. 6). Rosenfeld et al. (1999) and Gilje, Lacey and Moore (2007) identified curriculum overload as the greatest barrier to offering a stand-alone course. Rosenfeld et al. (1999) suggest that “programs should revise their curriculum to reflect the needs of the current and future health care markets and consider substituting gerontology for pediatrics” (p. 92). Rosenfeld et al. (2005) also recommended one strategy to solve curriculum overload. The authors “encourage programs to reconceptualize medical surgical nursing courses into geriatric courses by shifting the content and emphasis of existing medical surgical courses to more appropriately address the common response to illness and gerontological syndromes of older patients cared for on medical surgical hospital units” (Rosenfeld et al., 2005, p. 273).
Faculty preparation related to geriatrics and gerontology is a continuing issue because faculty preparation directly affects the offering and teaching of stand-alone courses (Gilje, Lacey & Moore, 2007). Rosenfeld et al. (1999) found that programs with at least one American Nurses Credentialing Center (ANCC) certified faculty member were more likely to have a stand-alone gerontological course. “One third of the respondents recognized that ‘lack of qualified full-time faculty members’ is a barrier to incorporating gerontological content into the curriculum (Rosenfeld et al., 1999, p. 92). Grocki and Fox (2004) focused their study on nursing curricula, but did mention that “Nursing programs across the United States support the inclusion of gerontology…however, it appears to be difficult to find faculty well-prepared in gerontology” (p. 47). Rosenfeld et al. (2005) determined there was a drop in ANCC-certified full-time faculty from 42% in 1997 to 37% in 2003. The authors recognize that strengthening faculty expertise in gerontology remains an important priority for the profession because nursing faculty who are teaching specialty courses need to be adequately prepared to do so (Rosenfeld et al., 2005). Gilje, Lacey and Moore (2007) in comparing their study with Rosenfeld et al. (1999) were unable to determine if there was an increasing trend toward ANCC-certified faculty. Although in 2007, 69% of public institutions had at least one faculty member who was ANCC-certified compared to only 34% private institutions which is similar to the results found in 1997 (Gilje, Lacey & Moore, 2007). The authors suggest further exploration regarding the relationship between faculty preparation, the extent to which AACN competencies are addressed and the offering of a stand-alone course (Gilje, Lacey & Moore, 2007).
The current study was intended to further investigate gerontological content in nursing curricula and the barriers concerning offering a stand-alone course (if any) within the state of Massachusetts. The collected data was analyzed and compared to the national data that has been previously collected by Gilje, Lacey and Moore (2007).
DESIGN AND METHODS
The population studied was the Registered Nurse programs in Massachusetts according to the Massachusetts Board of Registration for the 2006-2007 academic school year (Massachusetts Board of Registration in Nursing, 2007). There are 16 Baccalaureate of Science Nursing programs that comprise the population (N = 36) (MBORN, 2007).
A self-report paper-and-pencil questionnaire consistent with the purpose of the study was created after a review of the literature, including a review of past instruments used to survey gerontological nursing.
After analyzing each survey used, it was determined that the construction of the survey used for this study consisted of yes or no questions for ease of use. The survey was addressed to the faculty with responsibility for teaching the gerontological content at the respective school of nursing. The surveys were mailed to the appropriate faculty member, with addressed and stamped return envelopes. The respective faculty member was phoned and e-mailed regarding the survey prior to it being mailed and was phoned and e-mailed again three weeks post mailing to remind the faculty member to complete and mail the survey. This plan was developed with the hopes of generating a response rate higher than 60%.
Rosenfeld et al. (1999) categorized their survey into four sections. The survey for this study included three out of those four sections. The first section of the survey focused on gerontological content within the nursing curriculum.
The second section of the survey focused on possible barriers to incorporating gerontological content into the baccalaureate nursing curriculum (Rosenfeld et al., 1999). The primary barriers of “curriculum overload” and “lack of faculty preparation” were listed along with other barriers gathered from the previous studies. Finally, the third section concentrated on faculty characteristics, specifically with regard to faculty preparation (Rosenfeld et al., 1999).
Anonymity was assured and consent was assumed based on the voluntary return of the survey. Bias was eliminated by the sample selection and size, the use of a valid and reliable instrument and the use of data collection methods that are partially controlled by the environment (Burns & Grove, 2007). There is no manipulation of variables in the use of this descriptive study.
After completion of the literature review, construction of the tool and identification of the population of all Registered Nurse baccalaureate degree programs within Massachusetts by accessing the 2007 Annual Report from the Massachusetts Board of Registration in Nursing at www.mass.gov, the faculty member associated with the gerontological content at each of the baccalaureate degree programs within Massachusetts was identified. On March 4, 2008, each was contacted by phone and e-mail. Contact with the identified faculty member was initiated to provide information on the research being conducted and the mailing of the surveys on March 6.
The survey, a letter of the research being conducted and an addressed, stamped, return envelope was inserted into a manila envelope and mailed on March 6 to the identified faculty member at each institution. Contact was again initiated with the identified faculty member on March 14 as a reminder to complete and return the survey and to discuss any issues regarding the completion of the survey. All surveys returned to the researcher by April 3 were used as the study sample.
The sample population included six accredited baccalaureate nursing programs within Massachusetts, representing a 37.5% response rate.
In Massachusetts 33.2% of programs are offering a stand-alone course which is slightly higher than the national average, but still significantly low, suggesting that Massachusetts nursing students may be more qualified to care for the elderly than their peers, but are not being adequately qualified according to the AACN. 16.6% of programs require a gerontology course and 83.4% of programs integrate gerontology into other courses. The integration of gerontological material into other courses requires additional research to determine the amount of gerontology material actually covered.
The primary barriers to offering a stand-alone course in Massachusetts were identified from the collected data as curriculum overload, lack of qualified faculty and lack of quality clinical sites. These are partly consistent with the national findings from Rosenfeld et al. (1999) and Gilje, Lacey and Moore (2007) who identified curriculum overload and lack of qualified faculty to be the primary barriers to offering a stand-alone course.
100% of the 33.2% of programs that offer stand-alone courses in gerontology have an AACN certified faculty member. The researcher recognizes that strengthening faculty expertise in gerontology remains an important priority for the nursing profession because there is a direct correlation between faculty preparation and the offering of a stand-alone course.
Despite the low response rate, gerontology must be recognized as a specialty area by requiring stand-alone courses. In order for students to value the care of older people and to be prepared to meet the demands and rewards of caring for this population, gerontology should be afforded time within the baccalaureate curriculum, similar to that of other specialty areas. Administrative encouragement and support are vital for developing faculty expertise. The extent to which AACN competencies are covered and emphasized in both integrated nursing curricula and stand-alone courses is an issue that warrants further exploration.
Nursing students who are currently in a nursing program within Massachusetts and prospective students should be concerned with the content that will be offered in their curriculum. The content must be adequate to prepare them for the RN-NCLEX and for the workforce. If the demographics of the United States are rapidly changing, the nursing curricula should also be changing in accordance with the population that will primarily need nursing care.
The researcher suggests that further studies be done to address this issue.
American Association of Colleges of Nursing (AACN). (2000). Older adults: Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care. Retrieved November 18, 2007, from http://www.aacn.nche.edu/Education/pdf/Gercomp.pdf
Administration on Aging. (2004). Statistics: Aging into the 21st century. Retrieved November 18, 2007, from http://aoa.gov/prof/Statistics/future_growth/aging21/demography.asp
Burns, N., & Grove, S.K. (2007). Understanding nursing research: Building an evidenced base practice.
Gilje, F., Lacey, L., & Moore, C. (2007). Gerontology and geriatric issues and trends in U.S. nursing programs: A national survey. Journal of Professional Nursing, 23(1), 21-29.
Grocki, J.H., Fox, G.E. (2004). Gerontology coursework in undergraduate nursing programs in the United States: A regional study. Journal of Gerontological Nursing, 30(3), 46-51.
Ironside, P. (2004). “Covering content” and teaching thinking: Deconstructing the additive curriculum. Journal of Nursing Education, 43(1), 5-12.
Massachusetts Board of Registration in Nursing (MBORN). (2007). 2007 annual report. Retrieved November 9, 2007 from http://www.mass.gov/Eeohhs2/docs/dph/quality/boards/nursing_annual_report.pdf
Rosenfeld, P., Bottrell, M., Fulmer, T., & Mezey, M. (1999). Gerontological nursing content in baccalaureate nursing programs: Findings from a national survey. Journal of Professional Nursing, 15(2), 84-94.
Rosenfeld, P., Berman, A., Mezey, M., Kobayashi, M., Fulmer, T., Stanley, J. & Thornlow, D. (2005). Gerontological nursing content in baccalaureate nursing programs: Comparison of findings from 1997 and 2003. Journal of Professional Nursing, 21, 268-275.
Kristen Morris, SN* (Kristen graduated from Massachusetts College of Pharmacy and Health Sciences School of Nursing in May 2008 and recently passed the NCLEX-RN)
Carol Eliadi, APRN, EdD, JD (Assistant Dean and Associate Professor of Nursing, Massachusetts College of Pharmacy and Health Sciences School of Nursing)